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 ["24"]
Explanation
- Step 1: Identify the prescribed dose in units per hour. The client is scheduled to receive 1,200 units/hr of heparin.
- Step 2: Identify the concentration of the available solution. The available solution contains 25,000 units of heparin in 500 mL D5W.
- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 25,000 units is to 500 mL as 1,200 units is to X mL.
- In other words, 25,000 units : 500 mL = 1,200 units : X mL.
- Step 4: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 25,000 units × X mL = 1,200 units × 500 mL.
- Simplifying this gives us: 25,000X = 600,000.
- Dividing both sides by 25,000 gives us: X = 600,000 ÷ 25,000.
- Calculating the division gives us: X = 24.
Set the IV pump to deliver 24 mL/hr to administer the required dose of 1,200 units/hr.
Correct Answer is D
Explanation
Choice A reason: Hypermagnesemia, or high levels of magnesium in the blood, is not typically associated with refeeding syndrome. Instead, refeeding syndrome can lead to hypomagnesemia, which is a low level of magnesium in the blood, due to shifts of magnesium into the cells during insulin secretion in the refeeding process.
Choice B reason: Hyponatremia, or low levels of sodium in the blood, is not a hallmark of refeeding syndrome. While fluid shifts can affect sodium levels, the key electrolyte disturbances in refeeding syndrome involve phosphorus, potassium, and magnesium.
Choice C reason: Hyperkalemia, or high levels of potassium in the blood, is not a common finding in refeeding syndrome. Similar to magnesium, potassium can shift into cells during refeeding, which can actually lead to hypokalemia, or low levels of potassium in the blood.
Choice D reason: Hypophosphatemia, or low levels of phosphorus in the blood, is the hallmark of refeeding syndrome. When a malnourished individual is refed, insulin secretion is stimulated by the increased carbohydrate intake. Insulin promotes cellular uptake of glucose, which is accompanied by phosphate, potassium, and magnesium, leading to a decrease in the serum levels of these electrolytes. Phosphorus is critical for cellular processes, and its deficiency can lead to muscle weakness, respiratory failure, hemolysis, and impaired cardiac function. During refeeding, careful monitoring of electrolytes is essential to prevent and manage refeeding syndrome. Hypophosphatemia is the most significant laboratory finding to anticipate in a patient with refeeding syndrome, and it requires prompt recognition and treatment to prevent serious complications.
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