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 C
Explanation
C. Dietary factors, such as high intake of certain foods (e.g., animal protein, sodium, oxalate-rich foods) and low intake of others (e.g., fluids, calcium), can influence the composition of urine and contribute to the formation of renal stones. For example, calcium oxalate stones can form when there is an imbalance of calcium and oxalate in the urine, while uric acid stones can form in individuals with high purine diets.
A. The frequency of renal stones can vary depending on factors such as climate, dietary habits, and genetic predisposition, but it is not specifically associated with the northern United States.
B. Dehydration and inadequate fluid intake can contribute to the formation of renal stones, particularly calcium-based stones. Insufficient fluid intake can lead to concentrated urine, which increases the risk of stone formation and not vice versa.
D. The risk of renal stones is equal in both men and women.
Correct Answer is C
Explanation
C. The expected effect of TPN is to maintain or promote weight gain in clients who are unable to meet their nutritional needs orally. TPN provides essential nutrients directly into the bloodstream, allowing for adequate caloric intake to support energy needs and promote tissue repair and growth.
A. A serum white blood cell count of 16,000/mm3 indicates leukocytosis, which may suggest infection or inflammation rather than a direct effect of TPN.
B. Pre-albumin is a marker of nutritional status, and levels below 10 mg/dl typically indicate malnutrition rather than a positive response to TPN.
D. Negative nitrogen balance occurs when the body loses more nitrogen than it gains, typically due to inadequate protein intake or increased protein breakdown. TPN provides amino acids, which are the building blocks of protein, and aims to promote a positive nitrogen balance to support tissue repair and growth.
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