A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?
Perform abdominal palpation by pressing gently with the finger pads.
Determine areas of resonance across the abdomen using a systematic approach.
Expose the client's abdomen to look for changes in appearance.
Use the diaphragm of a stethoscope to listen for bowel sounds.
The Correct Answer is C
Choice A reason:
Palpation can help assess for tenderness, rigidity, or masses in the abdomen, which might indicate infection, bleeding, or other complications. However, palpation could potentially worsen a condition such as an evisceration or dehiscence, or cause additional pain. Therefore, palpation should be done only after the visual inspection and with great caution in the presence of severe pain.
Choice B reason:
Percussion is useful for assessing the presence of gas, fluid, or solid masses in the abdomen. Resonance might indicate normal air-filled intestines, while dullness could suggest fluid or mass. However, percussion is not the first action in an acute setting of sudden severe pain because it does not provide immediate information that could be life-saving. It is a later step in the physical examination.
Choice C reason:
Visual inspection is the first step because it can quickly reveal critical signs such as swelling, distention, redness, or evidence of wound complications like dehiscence or evisceration. Identifying these signs early allows for rapid intervention, which could be life-saving. This is why exposing and inspecting the abdomen is the priority in the context of sudden severe pain following surgery.
Choice D reason:
Listening for bowel sounds can provide information about the function of the gastrointestinal system. Absence of bowel sounds might suggest a paralytic ileus, while hyperactive sounds could indicate a bowel obstruction. However, in the context of sudden, severe abdominal pain postoperatively, auscultation is not the first priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
A blood glucose level of 110 mg/dl: A slightly elevated blood glucose level could be expected in response to enteral feeding.
Choice B reason:
Diarrhea one time in a 24-hour period is incorrect. Diarrhea can occur as a side effect of enteral feeding due to changes in the digestive process.
Choice C reason:
An unexpected finding when a client is receiving continuous enteral feeding via an NG tube is a rapid and significant weight gain of 0.91 kg (2 lb) in just 2 days. This could indicate fluid overload, which might be caused by excessive fluid intake or inadequate fluid removal by the body. Rapid weight gain should be assessed and reported as it could be a sign of underlying issues that need to be addressed.
Choice D reason:
A gastric residual of 300 mL at the end of the shift is incorrect. Gastric residuals can fluctuate during continuous enteral feeding, and a residual of 300 mL may not necessarily be unexpected depending on the client's overall condition and the healthcare provider's guidelines.
Correct Answer is A
Explanation
Choice A reason:
A. Dilated pupils
During the alarm reaction stage of the general adaptation syndrome (GAS), the body's initial response to stress triggers the "fight or flight" response. This response is characterized by the release of stress hormones, increased sympathetic nervous system activity, and various physiological changes to prepare the body to respond to the stressor. Dilated pupils are one of the manifestations of the fight or flight response, allowing for improved visual acuity and awareness of the environment.
Choice B reason:
Physical exhaustion is inappropriate. This is typically associated with the exhaustion stage of GAS, which follows the alarm reaction stage.
Choice C reason:
Bradycardia is inappropriate. Bradycardia (slow heart rate) is not a typical manifestation during the alarm reaction stage. Increased heart rate (tachycardia) is more common during this stage.
Choice D reason:
Depression is inappropriate. Depression is not a direct manifestation of the alarm reaction stage. It is a psychological response that may occur during or after prolonged stress and may be associated with the later stages of GAS.
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