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 C
Explanation
A. Steatorrhea:
Steatorrhea refers to the presence of excessive fat in the stool. If a healthcare provider suspects malabsorption or fat digestion issues, they might order a fecal fat test to assess the amount of fat in the stool. This test is different from a guaiac fecal occult blood test (gFOBT), which is designed to detect blood.
B. Parasites:
The detection of parasites in the stool involves specific testing methods, such as microscopic examination of stool samples or specialized tests aimed at identifying the presence of parasitic organisms. A guaiac fecal occult blood test is not designed to detect parasites; its primary purpose is to identify occult (hidden) blood.
C. Blood:
A stool test for guaiac is specifically designed to detect the presence of occult (hidden) blood in the stool. The guaiac test involves placing a small sample of stool onto a test card containing guaiac, and a color change indicates the presence of blood. This test is commonly used to screen for gastrointestinal bleeding.
D. Bacteria:
Detecting bacteria in the stool typically involves stool cultures or specific tests designed to identify bacterial infections or imbalances in the gut microbiota. The guaiac test is not intended for detecting bacteria; its primary focus is on identifying the presence of blood in the stool.
Correct Answer is A
Explanation
A. "Eat four small meals each day":
Smaller, more frequent meals reduce gastric distension and lower gastric pressure, which decreases reflux of stomach contents into the esophagus. Large meals increase intra-abdominal pressure and worsen GERD symptoms.
B. "Sleep on your left side":
Sleeping on the left side may reduce symptoms of GERD for some individuals. This position can keep the stomach below the esophagus, minimizing reflux. However, individual preferences and comfort should be considered.
C. "Wait to go to bed for 1 hour after eating":
This instruction helps reduce the risk of reflux while lying down. Waiting after eating allows gravity to aid in digestion and reduces the likelihood of stomach contents backing up into the esophagus during sleep.
D. "Drink milk to soothe your stomach":
While milk might provide temporary relief for some people by neutralizing stomach acid, it can stimulate acid production, potentially exacerbating GERD symptoms in the long run. Therefore, it's not a recommended solution for managing GERD.
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