A client with peptic ulcer disease (PUD) is admitted to the medical unit. Which assessment finding requires the most immediate intervention by the nurse?

A haemoglobin of 12 g/dL (7.45 mmol/L) and haematocrit of 42% (0.42 volume fraction).

Vital signs are temperature 99.0°F (37.2°C) orally, heart rate 94 beats/minute, respirations 18 breaths/minute, blood pressure 110/70 mm Hg.

Vomits coffee-grounds emesis.

Reports having sharp epigastric pain.

Answer and Explanation

The Correct Answer is C

Choice A reason: A haemoglobin level of 12 g/dL (7.45 mmol/L) and haematocrit of 42% (0.42 volume fraction) are slightly lower than the reference range but not critically low. This finding is important and needs to be monitored, but it does not require the most immediate intervention.

Choice B reason: The vital signs provided are within normal limits and do not indicate an urgent or life-threatening condition. These should be monitored, but they do not require immediate intervention compared to other findings.

Choice C reason: Vomiting coffee-grounds emesis is a sign of gastrointestinal bleeding, specifically indicating that blood has been in the stomach long enough to be partially digested by stomach acid, giving it a coffee-grounds appearance. This is a serious and potentially life-threatening condition requiring immediate medical intervention to stop the bleeding and prevent further complications.

Choice D reason: Sharp epigastric pain is a common symptom of peptic ulcer disease and indicates inflammation or ulceration. While it is painful and concerning, it does not require the most immediate intervention compared to active gastrointestinal bleeding.

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Correct Answer is B

Explanation

Choice A reason: Assessing peripheral pulses is important for understanding the client's overall circulatory status, but it is not the most urgent assessment in this situation. The client's symptoms suggest a possible thyrotoxic crisis, which requires immediate evaluation of critical vital signs.

Choice B reason: Obtaining vital signs is the most important initial assessment. The client's report of anxiety, heart racing, and pounding could indicate a severe exacerbation of hyperthyroidism, potentially leading to a thyrotoxic crisis (thyroid storm). Vital signs will provide essential information on the client's heart rate, blood pressure, temperature, and overall stability, which are crucial for immediate management.

Choice C reason: The presence of a goitre can indicates thyroid gland enlargement, which is relevant for long-term management of hyperthyroidism. However, it does not provide immediate information on the client's current acute condition.

Choice D reason: Assessing emotional status is important for comprehensive care, but it is not the priority in this acute scenario. The client's physiological status needs to be stabilized first, as indicated by their vital signs, before focusing on their emotional state.

A. Upper midabdominal pain described as gnawing and burning. B. Marked loss of weight and appetite over the last 3 or 4 months. C. Severe abdominal cramps and diarrhea after eating spicy foods. D. Frequent use of chewable and liquid antacids for indigestion.

Correct Answer is A

Explanation

Choice A reason: Upper midabdominal pain described as gnawing and burning is a classic symptom of peptic ulcer disease (PUD). This type of pain is typically located in the epigastric region and is often relieved by eating or taking antacids, which aligns with the presentation of PUD.

Choice B reason: Marked loss of weight and appetite over the last 3 or 4 months can occur in various gastrointestinal conditions, but it is not specific enough to support a diagnosis of PUD. This symptom alone does not provide enough evidence for PUD.

Choice C reason: Severe abdominal cramps and diarrhea after eating spicy foods might indicate irritable bowel syndrome (IBS) or another gastrointestinal condition. These symptoms are not typically associated with PUD.

Choice D reason: Frequent use of chewable and liquid antacids for indigestion can indicate chronic gastrointestinal discomfort, but it does not specifically point to PUD. It suggests ongoing gastric issues but lacks specificity for diagnosing PUD.

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A client with peptic ulcer disease (PUD) is admitted to the medical unit. Which assessment finding requires the most immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with hyperthyroidism tells the home health nurse, "I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding." Which assessment is most important for the nurse to obtain?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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