During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?
Nothing by mouth.
Electrocardiogram.
Monitor urinary output.
Complete bed rest.
The Correct Answer is A
Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis). Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Purulent secretions from eyes and nares is incorrect. Purulent secretions, which are thick and yellow or green in color, typically indicate the presence of a bacterial infection rather than allergic rhinitis. Allergic rhinitis is more commonly associated with clear nasal discharge, although it can sometimes be accompanied by a mild increase in nasal secretions.
Choice B Reason:
Snoring and bilateral, pale gray nodules is incorrect. Snoring and bilateral, pale gray nodules suggest adenoid hypertrophy rather than allergic rhinitis. Adenoid hypertrophy refers to enlargement of the adenoids, which are lymphoid tissue located in the back of the nasal cavity. Enlarged adenoids can lead to snoring and the presence of grayish nodules upon examination of the nasopharynx.
Choice C Reason:
Intranasal edema and swelling of turbinates are correct. Intranasal edema (swelling inside the nose) and swelling of turbinates are characteristic features of allergic rhinitis. Allergic rhinitis results from inflammation of the nasal mucosa in response to exposure to allergens, leading to nasal congestion and swelling of the turbinates.
Choice D Reason:
Eye tearing and thick yellow nasal drainage is incorrect. Eye tearing and thick yellow nasal drainage suggest the presence of sinusitis rather than allergic rhinitis. Sinusitis is characterized by inflammation of the sinuses, which can result in symptoms such as facial pain or pressure, thick nasal discharge, and eye tearing due to sinus pressure affecting the tear ducts.
Correct Answer is B
Explanation
Choice A Reason:
Chronic pancreatitis is incorrect. Chronic pancreatitis typically presents with persistent, dull abdominal pain that may radiate to the back, often aggravated by eating rather than relieved by it. The pain associated with chronic pancreatitis is not typically described as gnawing or relieved by eating.
Choice B Reason:
Peptic ulcer disease (PUD) is correct. Peptic ulcer disease involves the development of open sores (ulcers) in the lining of the stomach (gastric ulcers) or the upper part of the small intestine (duodenal ulcers). The pain associated with PUD typically occurs in the epigastric region (upper abdomen) and can be described as gnawing, burning, or dull. The pain tends to worsen when the stomach is empty (hunger pains) and is relieved by eating or taking antacids. These symptoms are due to the increase in gastric acid secretion, which exacerbates the ulcer's irritation when the stomach is empty and is neutralized when food buffers the acid. Therefore, the presentation described is consistent with peptic ulcer disease (PUD).
Choice C Reason:
Esophagitis is incorrect. Esophagitis is inflammation of the esophagus and may present with symptoms such as heartburn, difficulty swallowing, or chest pain behind the breastbone. However, the symptoms described, particularly the worsening of pain when hungry and improvement after eating, are not typical of esophagitis.
Choice D Reason:
Gastroesophageal reflux (GERD) is incorrect. While gastroesophageal reflux disease (GERD) can cause epigastric discomfort or heartburn, the symptoms described in the scenario are more indicative of pain related to hunger and relief after eating, which is more characteristic of peptic ulcer disease (PUD). Additionally, GERD symptoms are typically worsened by eating, lying down, or bending over, rather than improved.
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