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 B
Explanation
Choice A: Increase the client’s sodium intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s sodium intake can worsen fluid retention and exacerbate ascites. The nurse should recommend limiting the client’s sodium intake to less than 2 g per day.
Choice B: Decrease the client’s fluid intake. This is an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. Ascites is a complication of cirrhosis that involves the accumulation of fluid in the peritoneal cavity. Decreasing the client’s fluid intake can help reduce fluid retention and prevent further distension of the abdomen and pressure on the diaphragm.
Choice C: Increase the client’s saturated fat intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s saturated fat intake can increase the risk of cardiovascular disease, obesity, and faty liver disease. The nurse should recommend a balanced diet that provides adequate protein, calories, vitamins, and minerals.
Choice D: Decrease the client’s carbohydrate intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Decreasing the client’s carbohydrate intake can cause ketosis, which is a metabolic state that occurs when the body uses fat as a fuel source instead of glucose.
Ketosis can cause nausea, fatigue, headache, and bad breath. The nurse should recommend a moderate carbohydrate intake that provides enough glucose for energy and prevents ketosis.
Correct Answer is D
Explanation
Choice A: Notify the nurse manager. This is an important action that the nurse should take, but not a priority. The nurse should notify the nurse manager to report the error and seek guidance on how to proceed. The nurse manager can also provide support and feedback to the nurse and help prevent similar errors in the future.
Choice B: Give the client 15 to 20 g of carbohydrate. This is a necessary action that the nurse should take, but not the priority. The nurse should give the client 15 to 20 g of carbohydrates to raise their blood glucose level and prevent or treat hypoglycemia. The nurse should choose a fast-acting carbohydrate source, such as juice, glucose tablets, or candy.
Choice C: Complete an incident report. This is a required action that the nurse should take, but not the priority. The nurse should complete an incident report to document the error and its consequences. The incident report can help identify the root cause of the error and improve patient safety and quality of care.
Choice D: Check the client’s blood glucose level. This is the priority action that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should check the client’s blood glucose level to confirm the error and assess the risk of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause symptoms such as sweating, trembling, confusion, and loss of consciousness. It can be life-threatening if not treated promptly.
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