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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["60"]
Explanation
- Step 1: Identify the required dose in grams. The client is scheduled to receive 30 grams of lactulose.
- Step 2: Identify the concentration of the available solution. The available solution contains 5 grams of lactulose per 10 mL.
- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 5 grams is to 10 mL as 30 grams is to X mL.
- In other words, 5 g : 10 mL = 30 g : X mL.
- Step 4: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 5 g × X mL = 30 g × 10 mL.
- Simplifying this gives us: 5X = 300.
- Dividing both sides by 5 gives us: X = 300 ÷ 5.
- Calculating the division gives us: X = 60.
60 mL of the lactulose solution should be poured into the medication cup to administer the required dose of 30 grams.
Correct Answer is C
Explanation
Choice A reason:Shaking the bag is not recommended as it may not adequately mix the solution and could cause emulsion instability.
Choice B reason:Administering the bag as is could be harmful due to the risk of fat embolism or other complications from an unstable emulsion.
Choice C reason:Returning the bag to the pharmacy is the appropriate action to ensure the client receives a properly mixed and safe emulsion.
Choice D reason:Turning the bag upside down one time is not sufficient to mix the emulsion and does not address the potential instability of the solution.
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