The nurse is caring for an older adult in the medical-surgical unit:
84-year-old female was admitted to the medical-surgical unit with a three-day history of abdominal pain, distention, nausea, and persistent vomiting. She reports that she has not had a bowel movement in five days and has no appetite.
Which of the following findings are consistent with a small bowel obstruction: Select all that apply.
Right lower quadrant abdominal pain
Fever
Nausea and vomiting
Unable to pass stool
distended abdomen
Correct Answer : C,D,E
Choice A rationale: Small bowel obstructions typically present with diffuse, crampy abdominal pain rather than localized pain in the right lower quadrant.
Choice B rationale: While fever can be present in some cases, it's not a consistent finding with small bowel obstruction unless there's perforation.
Choice C rationale: Common symptoms of small bowel obstruction due to the buildup of contents proximal to the obstruction.
Choice D rationale: A key feature of small bowel obstruction due to the blockage preventing normal bowel movements.
Choice E rationale: Accumulation of gas and fluid above the obstruction causes abdominal distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: This patient is likely experiencing hyperosmolar hyperglycemic state (HHS). Rapid administration of IV fluids is crucial to correct severe dehydration associated with HHS.
Choice B rationale: Routine insulin therapy and exercise might be components of diabetes management but wouldn't directly address the immediate concern of severe dehydration and high blood glucose.
Choice C rationale: Cardiac monitoring for potassium changes might be necessary but isn't the primary immediate intervention for HHS.
Choice D rationale: Administering a different antibiotic for the UTI is incorrect, because there is no evidence that the current antibiotic is ineffective or causing adverse effects. The UTI may have triggered the HHS, but it is not the main problem that needs to be addressed urgently.
Correct Answer is C
Explanation
Choice A rationale: Pulmonary embolism would cause chest pain, dyspnea, and hemoptysis, but not petechiae or neurological changes.
Choice B rationale: While chest pain might be associated with myocardial infarction, the combination of symptoms aligns more with a pulmonary embolism.
Choice C rationale: Fat embolism syndrome occurs when fat globules from the bone marrow enter the bloodstream and travel to the lungs, brain, or other organs. This can
cause respiratory distress, neurological impairment, petechiae (reddish-purple spots on the skin), and cardiac dysfunction.
Choice D rationale: Compartment syndrome doesn't typically manifest with respiratory symptoms or reddish-purple spots.
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