A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?
Sudden thirst, unrelieved by oral fluid administration
Tachycardia, hypotension, and tachypnea
Diaphoresis and sudden onset of abdominal pain
Tarry, foul-smelling stools
The Correct Answer is B
Choice A reason:
While thirst can be a sign of dehydration, it is not specific to recurrence of a GI bleed.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of a GI bleed and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to recurrence of a GI bleed.
Choice D reason:
Tarry, foul-smelling stools are indicative of melena, which is a sign of a GI bleed. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A: This response minimizes the client's feelings and may make them feel unheard. It's important for healthcare providers to acknowledge a patient's feelings and provide reassurance in a more empathetic manner.
- B: This response delays addressing the client's concerns and may increase his anxiety. Consent is important, but it should not be a barrier to discussing care and addressing concerns.
- C: This response is factual but does not address the client's immediate concern about pain. It's crucial to address the client's fears directly rather than deflecting to the procedure's necessity.
- D: This response directly addresses the client's concern about pain by informing him of the sedative, which is a common practice to reduce discomfort during a colonoscopy. It provides reassurance and factual information about the procedure's process.
Correct Answer is A
Explanation
Choice A reason:
Asterixis is a characteristic sign of hepatic encephalopathy, characterized by a flapping tremor of the hands. It is associated with liver dysfunction and is indicative of impaired ammonia metabolism in the brain.
Choice B reason:
Fetor hepaticus refers to a musty, sweet odor of the breath that is associated with severe liver disease. It is not related to the flapping tremor observed in this case.
Choice C reason:
Palmar erythema is a reddening of the palms and is associated with various conditions, including liver disease. However, it is not the sign described in the scenario.
Choice D reason:
Constructional apraxia is a neurological deficit characterized by difficulty in copying or constructing simple drawings or designs. It is not related to the flapping tremor seen in hepatic encephalopathy.
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