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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Limit fluid intake not related to meals:
While staying hydrated is important, it's generally recommended to limit fluid intake not related to meals to avoid overfilling the stomach and putting excess pressure on the lower esophageal sphincter (LES). However, this is not as specific to GERD management as the option B.
B. Avoid eating within 3 hours of bedtime:
This is a key recommendation for managing GERD. Eating close to bedtime increases the likelihood of stomach contents refluxing into the esophagus when lying down. Waiting at least 3 hours after eating before lying down can help prevent symptoms.
C. Chew on mint leaves to relieve indigestion:
Mint, including mint leaves, can relax the LES, potentially worsening GERD symptoms. It is not recommended for managing GERD.
D. Season foods with black pepper:
While black pepper itself is not a common trigger for GERD, highly spicy or peppery foods can sometimes exacerbate symptoms in individuals with GERD. It's advisable to pay attention to personal triggers and adjust the diet accordingly.
Correct Answer is B
Explanation
A. Lactulose is not used to decrease potassium levels. It is a laxative that works by drawing water into the colon, softening stools and promoting bowel movements.
B. Lactulose is used to decrease ammonia levels in clients with cirrhosis. Ammonia is a byproduct of protein metabolism, and when the liver is compromised, it may not effectively convert ammonia into urea, leading to elevated ammonia levels in the bloodstream. Lactulose helps reduce ammonia absorption in the colon.
C. Lactulose does not decrease glucose levels significantly. It is not primarily used as an antidiabetic medication.
D. Lactulose does not affect bicarbonate levels significantly. It primarily targets ammonia reduction in clients with cirrhosis.
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