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: Check for bleeding on the dressing at the back of the client’s neck. This is an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy, which is a surgical removal of part of the thyroid gland. The nurse should check for bleeding on the dressing at the back of the client’s neck because this is where blood can pool and go unnoticed. Bleeding can cause hematoma, compression of the airway, and respiratory distress.
Choice B: Ensure that acetylcysteine IV is readily available. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Acetylcysteine IV is an antidote for acetaminophen overdose, which can cause liver damage, but it is not related to thyroid surgery.
Choice C: Place the client in a side-lying position. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. The nurse should place the client in a semi-Fowler’s position, which is a position with the head of the bed elevated to 30 to 45 degrees. This position can facilitate breathing, reduce edema, and prevent aspiration.
Choice D: Check the client for asterixis. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Asterixis is a sign of hepatic encephalopathy, which is a condition caused by liver failure, but it is not related to thyroid surgery.
Correct Answer is B
Explanation
Choice A: Upper left quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper left quadrant of the abdomen contains organs such as the stomach, spleen, pancreas, and part of the colon. Abdominal pain in this area can indicate conditions such as gastritis, peptic ulcer, pancreatitis, splenomegaly, or colon cancer.
Choice B: Lower left quadrant. This is the location where the nurse should expect the client to report abdominal pain who has diverticular disease, which is a condition that involves the formation of pouches or sacs in the wall of the colon. These pouches or sacs are called diverticula, and they can become inflamed or infected, causing diverticulitis. Diverticulitis can cause abdominal pain, fever, nausea, vomiting, and changes in bowel habits. The most common site of diverticula formation and diverticulitis is the sigmoid colon, which is located in the lower left quadrant of the abdomen.
Choice C: Upper right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper right quadrant of the abdomen contains organs such as the liver, gallbladder, duodenum, and part of the colon. Abdominal pain in this area can indicate conditions such as hepatitis, cholecystitis, duodenal ulcer, or colon cancer.
Choice D: Lower right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The lower right quadrant of the abdomen contains organs such as the appendix, cecum, and part of the colon. Abdominal pain in this area can indicate conditions such as appendicitis, Crohn’s disease, or colon cancer.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.