A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?
Bradycardia
Hyperactive bowel sounds
Report of epigastric fullness
Severe upper abdominal pain
The Correct Answer is D
Choice A: Bradycardia. This is not a manifestation of gastrointestinal perforation, but rather a sign of vagal stimulation, which can occur in response to gastric distension, vomiting, or suctioning. Vagal stimulation can slow down the heart rate and lower the blood pressure.
Choice B: Hyperactive bowel sounds. This is not a manifestation of gastrointestinal perforation, but rather a sign of increased intestinal motility, which can occur in response to inflammation, infection, or irritation of the gastrointestinal tract. Hyperactive bowel sounds are loud, high-pitched, and frequent.
Choice C: Report of epigastric fullness. This is not a manifestation of gastrointestinal perforation, but rather a sign of delayed gastric emptying, which can occur in response to gastric outlet obstruction, gastroparesis, or pyloric stenosis. Epigastric fullness is a feeling of pressure or discomfort in the upper abdomen after eating.
Choice D: Severe upper abdominal pain. This is a manifestation of gastrointestinal perforation, which is a life-threatening complication of peptic ulcer disease. Peptic ulcer disease is a condition that causes erosion and ulceration of the mucosal lining of the stomach or duodenum. If the ulcer penetrates through the wall of the gastrointestinal tract, it can cause perforation, which is a hole that allows gastric contents to leak into the peritoneal cavity. This can cause peritonitis, which is an inflammation and infection of the peritoneum. Peritonitis can cause severe upper abdominal pain, which may radiate to the shoulder or back. The pain may be sudden, sharp, and constant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.
Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.
Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.
Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that attacks the beta cells and causes type 1 diabetes mellitus.
Correct Answer is D
Explanation
Choice A: Measure the tube for insertion from the tip of the nose to the umbilicus. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should measure the tube for insertion from the tip of the nose to the earlobe and then to the xiphoid process, which is a more accurate way of estimating the length of the tube needed to reach the stomach.
Choice B: Place the client in a supine position. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should place the client in a high-Fowler’s position, which is a position with the head of the bed elevated to 90 degrees. This position can prevent aspiration, promote breathing, and allow gravity to assist with the insertion of the tube.
Choice C: Withdraw the tube if the client gags during insertion. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should not withdraw the tube if the client gags during insertion, as this can cause trauma to the nasal or pharyngeal mucosa and increase discomfort. The nurse should pause and allow the client to rest and breathe until gagging subsides, then resume insertion. The nurse should also provide reassurance and encouragement to the client throughout the procedure.
Choice D: Instruct the client to place his chin to his chest and swallow. This is an intervention that the nurse should take when inserting a nasogastric tube, which is a flexible tube that is inserted through the nose and into the stomach. The nurse should instruct the client to place his chin to his chest and swallow as the tube passes through the pharynx and into the esophagus. This can facilitate the insertion of the tube and prevent it from entering the trachea or causing injury to the nasal or pharyngeal mucosa.
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