A nurse is caring for a client diagnosed with peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?
Bradycardia
Hyperactive bowel sounds
Increased blood pressure
Sudden abdominal pain
The Correct Answer is D
A. Bradycardia is not typically associated with gastrointestinal perforation. Instead, tachycardia may be observed due to the body's response to a potential emergency or shock.
B. Hyperactive bowel sounds are not typically associated with gastrointestinal perforation. In fact, bowel sounds may decrease or become absent in severe cases of peritonitis or abdominal emergencies.
C. Increased blood pressure is not typically associated with gastrointestinal perforation. Hypotension may be observed due to hypovolemia resulting from fluid leakage into the peritoneal cavity.
D. Sudden abdominal pain is a key clinical manifestation of gastrointestinal perforation. The perforation of the stomach or intestines allows the contents to leak into the abdominal cavity, leading to peritonitis. Sudden and severe abdominal pain is a hallmark symptom, often described as sharp, stabbing, and constant.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide oral hygiene.
Providing oral hygiene is important for the client's comfort and overall well-being. However, in the context of acute pancreatitis, the immediate priority is to address the gastrointestinal symptoms and prevent further pancreatic stimulation.
B. Assist the client to a side-lying position.
Assisting the client to a side-lying position can be beneficial for comfort and may help prevent complications such as aspiration. However, it is not the immediate priority after treating the pain. Withholding oral fluids and food takes precedence in the initial management of acute pancreatitis.
C. Auscultate the client's lungs.
Auscultating the client's lungs is a routine nursing assessment and is important for respiratory monitoring. However, in the context of acute pancreatitis, the primary focus is on addressing gastrointestinal symptoms, and respiratory assessment becomes more critical if respiratory distress is suspected.
D. Withhold oral fluids and food.
Withholding oral fluids and food is the priority intervention after treating the pain in acute pancreatitis. This is done to reduce pancreatic stimulation, allowing the pancreas to rest and recover. NPO (nothing by mouth) status is often initiated in the early management of acute pancreatitis.
Correct Answer is B
Explanation
A. Level of consciousness:
While assessing the client's level of consciousness is important, it is not the top priority after an EGD procedure unless there are specific signs of neurological distress. Monitoring for signs of sedation or anesthesia recovery is typically part of post-procedure care.
B. Gag reflex:
This is the correct answer. The nurse should prioritize assessing the gag reflex, as the procedure involves passing a flexible tube through the mouth and down the esophagus. Ensuring the return of the gag reflex is essential to prevent aspiration and ensure the client's safety.
C. Pain:
Pain assessment is important, but it is usually addressed after confirming airway protection and ensuring the absence of complications such as bleeding or perforation.
D. Nausea:
While nausea is a possible post-procedure symptom, assessing the gag reflex and monitoring for signs of complications take precedence over managing nausea in the immediate post-procedure period.
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