The nurse is caring for a client who has a history of peptic ulcer disease and is being admitted to the hospital with clinical manifestations of a perforation. Which finding by the nurse would best Indicate that perforation has occurred?
Numbness in the legs
Rebound tenderness on abdominal palpation
Projectile vomiting of undigested food
Jaundice of the skin and sclera
The Correct Answer is B
B. Rebound tenderness on abdominal palpation: Rebound tenderness, where pain increases upon release of pressure during abdominal palpation, is a classic sign of peritonitis, which can occur due to a peptic ulcer perforation. It indicates irritation of the peritoneum, the lining of the abdominal cavity, which can occur when stomach contents leak into the peritoneal cavity.
A. Numbness in the legs is not typically associated with perforation of a peptic ulcer. Perforation of a peptic ulcer usually presents with localized abdominal symptoms rather than symptoms in the legs.
C. Projectile vomiting of undigested food is not typically associated with perforation of a peptic ulcer. It is more commonly seen in conditions such as pyloric stenosis or gastrointestinal obstruction.
D. Jaundice, a yellow discoloration of the skin and sclera, is not typically associated with perforation of a peptic ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Obtaining blood and urine specimens for culture and sensitivity is a critical first step. These specimens help identify the causative organism(s) and determine their susceptibility to antibiotics, guiding appropriate antibiotic therapy. Prompt initiation of targeted antibiotic treatment is essential in managing sepsis effectively.
A. This action is important for assessing the presence of any urinary tract stones or debris, which can be helpful in diagnosing the cause of the urinary tract infection. However, it is not the first action the nurse should take in managing a client admitted with sepsis secondary to a urinary tract infection.
C. Administering antibiotics before obtaining appropriate cultures may lead to empirical treatment without knowing the specific pathogen causing the infection. It is important to obtain cultures first to guide antibiotic selection and ensure optimal treatment.
D. Contact precautions may be necessary if the client is found to have a multidrug-resistant organism or if there are specific infection control concerns. However, placing the client on contact precautions is not the first action the nurse should take in managing sepsis secondary to a urinary tract infection.
Correct Answer is C
Explanation
A. Emptying the bladder before and after sexual intercourse can help flush out bacteria that may have entered the urethra during sexual activity, reducing the risk of UTIs. Therefore, this statement indicates effective understanding of preventive measures.
B. Regularly emptying the bladder helps prevent the buildup of bacteria in the urinary tract, reducing the risk of UTIs. Therefore, this statement indicates effective understanding of preventive measures.
C. Using vaginal sprays and douches can disrupt the natural balance of bacteria in the vagina and increase the risk of UTIs and other vaginal infections. Therefore, this statement indicates a misunderstanding of preventive measures and could potentially contribute to an increased risk of UTIs.
D. Wiping from front to back after urination helps prevent the spread of bacteria from the anal area to the urethra, reducing the risk of UTIs. Therefore, this statement indicates effective understanding of preventive measures.
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