A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).

Tachycardia

Rebound tenderness

Rigid abdomen

Elevated blood pressure

Answer and Explanation

Correct Answer : A,B,C

Tachycardia, or a rapid heartbeat, is a common response to the pain and stress associated with stomach perforation. The body’s sympathetic nervous system is activated in response to the pain and the potential shock state due to internal bleeding or infection, leading to an increased heart rate. Tachycardia is also a compensatory mechanism to maintain adequate blood flow and oxygen delivery to vital organs in the setting of decreased blood volume. A stomach perforation due to a peptic ulcer is a serious medical condition where an ulcer has led to a hole in the stomach lining. This can lead to the contents of the stomach spilling into the abdominal cavity, causing peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity).

Choice B: Rebound tenderness

Rebound tenderness is a clinical sign that indicates irritation of the peritoneum. When pressure is applied to the abdomen and then quickly released, the sudden movement of the peritoneal layers against each other produces sharp, rebound pain. This is a classic sign of peritonitis, which can occur with stomach perforation as gastric contents irritate the peritoneum. When assessing a client with a suspected stomach perforation due to a peptic ulcer, a nurse should expect to find signs of tachycardia, rebound tenderness, and a rigid abdomen. These findings are indicative of the body’s response to the acute abdominal condition and peritoneal irritation. It is crucial to recognize these signs promptly as stomach perforation is a medical emergency requiring immediate intervention.

Choice C: Rigid abdomen

A rigid abdomen is indicative of involuntary guarding, a reflex contraction of the abdominal muscles to protect inflamed organs within the abdomen. This rigidity is a sign of peritoneal irritation and is often present in cases of stomach perforation. The rigidity helps to immobilize the area, which may reduce pain but also serves as a clinical indicator of serious intra-abdominal pathology.

Choice D: Elevated blood pressure

Elevated blood pressure is not typically a direct result of stomach perforation. In fact, blood pressure may initially be normal or even low, depending on the body’s response to internal bleeding and the potential development of shock. However, pain and anxiety can cause a transient increase in blood pressure, but it is not a primary diagnostic criterion for stomach perforation.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Hypoxemia, or low oxygen levels in the blood, is a primary indicator of ARF as the lungs are unable to adequately oxygenate the blood.

Choice B reason: Confusion can result from hypoxemia or hypercapnia (high carbon dioxide levels) as the brain is sensitive to changes in blood gas levels.

Choice C reason: Dyspnea, or difficulty breathing, is a hallmark symptom of ARF as the lungs struggle to maintain adequate gas exchange.

Choice D reason: Bradycardia, or a slow heart rate, is not typically associated with ARF. Tachycardia, or a fast heart rate, is more common as the body attempts to compensate for hypoxemia.

Choice E reason: Hypocarbia, or low carbon dioxide levels, can occur in ARF if the body is attempting to compensate for hypoxemia by hyperventilating.

A. "Both heparin and warfarin work together to dissolve the clots." B. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." C. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay." D. "I will call the provider to get a prescription for discontinuing the IV heparin today."

Correct Answer is B

Explanation

Choice A reason: Heparin and warfarin do not work together to dissolve clots. Heparin acts quickly to prevent further clotting, while warfarin is used for long-term anticoagulation.

Choice B reason: Warfarin's onset of action is slow, requiring several days to reach therapeutic levels. During this time, heparin is used to provide immediate anticoagulation to prevent new clot formation or the growth of existing clots.

Choice C reason: IV heparin does not increase the effects of warfarin. They are used concurrently because of the delay in warfarin's onset of action.

Choice D reason: It is not appropriate to discontinue heparin immediately after starting warfarin due to the delay in warfarin reaching therapeutic levels. The overlap is necessary to ensure continuous anticoagulation.

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A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).

Nursing Test Bank

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Explanation

Correct Answer is B

Explanation

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