A 72-year-old patient was admitted with epigastric pain caused by a peptic ulcer. Which patient assessment warrants an urgent change in the nursing plan of care?
Chest pain relieved with eating or drinking water
Burning epigastric pain 90 minutes after breakfast
Back pain three or four hours after eating a meal
Rigid abdomen and vomiting following indigestion
The Correct Answer is D
Choice A rationale
Chest pain that is relieved with eating or drinking water is not typically indicative of a complication from a peptic ulcer. This symptom may be related to conditions like gastroesophageal reflux disease (GERD).
Choice B rationale
Burning epigastric pain after eating is a common symptom of a peptic ulcer and, while uncomfortable, does not usually require an urgent change in the plan of care unless it significantly worsens or is accompanied by other concerning symptoms.
Choice C rationale
Back pain after eating can be associated with a peptic ulcer if the ulcer is located at the back of the stomach or the pain radiates; however, it does not typically warrant an urgent change in care without other symptoms.
Choice D rationale
A rigid abdomen and vomiting following indigestion can indicate a perforated ulcer, which is a medical emergency. This requires immediate intervention and possibly surgical consultation, thus warranting an urgent change in the nursing plan of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Anxiety, while a valid concern, is not directly a risk associated with the physical complications of an ileal conduit. However, it can be an emotional response to the surgery and the changes it brings.
Choice B rationale
Impaired skin integrity is a significant risk for clients with an ileal conduit due to the potential for irritation from the stoma appliance and the risk of skin breakdown around the stoma site.
Choice C rationale
Infection is a risk due to the potential for bacteria to enter through the stoma or for urinary tract infections to develop, given the changes in the urinary system's structure and function.
Choice D rationale
Fluid volume deficit is a risk for clients with an ileal conduit because of the potential for increased fluid loss through the stoma, necessitating careful monitoring and management of fluid intake and output.
Choice E rationale
Disturbed body image is a risk due to the physical changes and the presence of a stoma, which can affect the client's perception of their body and self-image.
Correct Answer is B
Explanation
Choice A rationale
The red blood cell (RBC) count is not typically affected by hemodialysis. Hemodialysis is a process that primarily targets the removal of waste products and excess fluid from the blood, not red blood cells.
Choice B rationale
Potassium levels are often elevated in clients with renal failure due to the kidneys' inability to excrete potassium. Hemodialysis helps to remove excess potassium from the bloodstream, thereby decreasing its levels.
Choice C rationale
Calcium levels can be affected by hemodialysis; however, they are more often managed with medication and diet rather than being directly targeted by the dialysis process itself.
Choice D rationale
Protein levels should not decrease significantly as a result of hemodialysis. The dialysis membrane is designed to allow small waste products to pass through while retaining larger molecules like proteins.
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