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 C
Explanation
A. Calcium:
While calcium levels can be affected in pancreatitis, it is more commonly associated with a decrease in calcium levels due to fat necrosis and the formation of calcium soaps. However, the primary electrolyte disturbance is more likely to involve magnesium.
B. Magnesium:
Magnesium levels may be decreased in acute pancreatitis due to factors such as vomiting, malabsorption, and poor oral intake. Hypomagnesemia is a possible consequence, but it's not as specific to pancreatitis as the elevation of amylase.
C. Amylase:
Elevated amylase levels are a hallmark of acute pancreatitis. Amylase is an enzyme released by the pancreas, and its elevation in the blood is a key diagnostic marker for pancreatitis.
D. RBC count:
Acute pancreatitis does not typically result in a significant impact on the red blood cell (RBC) count. The elevation of amylase and lipase levels, along with imaging studies, is more indicative of pancreatitis.
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