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. Increase fiber in the diet: This is the correct option. Increasing dietary fiber intake is one of the most important interventions to prevent diverticular disease and reduce the risk of diverticulitis. Adequate fiber intake promotes regular bowel movements and prevents constipation, which can help reduce pressure in the colon and minimize the formation of diverticula.
A. Nuts and seeds are excellent sources of dietary fiber, which may actually help prevent diverticular disease. Therefore, while avoiding nuts and seeds may be advised during an acute diverticulitis flare-up to reduce irritation to the colon, it is not the most important long-term preventive intervention.
C. While stress management techniques may contribute to overall health and well-being, they are not the most important intervention specifically for preventing diverticular disease.
D. While physical activity and exercise are important for overall health and may help improve bowel function, there is limited evidence to suggest that strengthening abdominal muscles alone can prevent diverticular disease.
Correct Answer is ["A","B","D","E"]
Explanation
A. Keeping the client NPO (nothing by mouth) helps to rest the gastrointestinal tract, reduces the risk of further obstruction, and prevents exacerbation of symptoms such as vomiting.
B. Measuring abdominal girth is an important nursing assessment for a client with a possible small bowel obstruction. An increase in abdominal girth can indicate abdominal distension, which is a common sign of bowel obstruction.
C. Severe abdominal pain is a common symptom of bowel obstruction, and opioids may be necessary to manage pain effectively. However, opioids should be used cautiously due to the risk of exacerbating bowel obstruction by reducing bowel motility.
D. Fluid replacement therapy is important for clients with small bowel obstruction, especially if they are vomiting or have fluid loss due to intestinal secretions. Intravenous fluids may be administered to maintain hydration, correct electrolyte imbalances, and prevent dehydration.
E. Radiologic studies, such as abdominal X-rays or computed tomography (CT) scans, are often used to confirm the diagnosis of small bowel obstruction and assess its severity.
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