A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).

Tachycardia

Rebound tenderness

Rigid abdomen

Elevated blood pressure

Answer and Explanation

Correct Answer : A,B,C

Tachycardia, or a rapid heartbeat, is a common response to the pain and stress associated with stomach perforation. The body’s sympathetic nervous system is activated in response to the pain and the potential shock state due to internal bleeding or infection, leading to an increased heart rate. Tachycardia is also a compensatory mechanism to maintain adequate blood flow and oxygen delivery to vital organs in the setting of decreased blood volume. A stomach perforation due to a peptic ulcer is a serious medical condition where an ulcer has led to a hole in the stomach lining. This can lead to the contents of the stomach spilling into the abdominal cavity, causing peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity).

Choice B: Rebound tenderness

Rebound tenderness is a clinical sign that indicates irritation of the peritoneum. When pressure is applied to the abdomen and then quickly released, the sudden movement of the peritoneal layers against each other produces sharp, rebound pain. This is a classic sign of peritonitis, which can occur with stomach perforation as gastric contents irritate the peritoneum. When assessing a client with a suspected stomach perforation due to a peptic ulcer, a nurse should expect to find signs of tachycardia, rebound tenderness, and a rigid abdomen. These findings are indicative of the body’s response to the acute abdominal condition and peritoneal irritation. It is crucial to recognize these signs promptly as stomach perforation is a medical emergency requiring immediate intervention.

Choice C: Rigid abdomen

A rigid abdomen is indicative of involuntary guarding, a reflex contraction of the abdominal muscles to protect inflamed organs within the abdomen. This rigidity is a sign of peritoneal irritation and is often present in cases of stomach perforation. The rigidity helps to immobilize the area, which may reduce pain but also serves as a clinical indicator of serious intra-abdominal pathology.

Choice D: Elevated blood pressure

Elevated blood pressure is not typically a direct result of stomach perforation. In fact, blood pressure may initially be normal or even low, depending on the body’s response to internal bleeding and the potential development of shock. However, pain and anxiety can cause a transient increase in blood pressure, but it is not a primary diagnostic criterion for stomach perforation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: A client who works in a child care center is not typically at risk for hepatitis C unless they are exposed to blood or bodily fluids from an infected individual. Hepatitis C is primarily spread through blood-to-blood contact. While working in a child care center may increase the risk of exposure to various infections due to close contact with children, it is not a common route of transmission for hepatitis C.

Choice B reason: Eating raw shellfish is more commonly associated with hepatitis A and E, which are transmitted through the fecal-oral route, often due to contaminated food or water. Hepatitis C, however, is not typically transmitted through food or water. It is a bloodborne virus, and thus, eating raw shellfish would not be considered a high-risk activity for contracting hepatitis C.

Choice C reason: A client who has multiple tattoos is at risk for developing hepatitis C, particularly if the tattoos were done using non-sterile equipment or in an unregulated setting. The hepatitis C virus can be transmitted through the use of contaminated needles, which can occur in tattoo parlors that do not adhere to strict hygiene and sterilization practices. This is why choice C is the correct answer. While all the options presented could potentially involve some risk of infection, it is the client with multiple tattoos who is most at risk for hepatitis C, assuming the tattoos were obtained in a setting where infection control practices were not followed. It’s important for healthcare providers to assess each client’s individual risk factors and educate them on the ways to prevent hepatitis C, such as ensuring the use of sterile needles for tattoos and piercings.

Choice D reason: Traveling to an underdeveloped country may increase the risk of various infectious diseases, but hepatitis C is not commonly spread through casual contact or environmental factors. It requires blood-to-blood contact for transmission. Therefore, unless the client engaged in activities that involved such exposure, like receiving medical or dental procedures with non-sterile equipment, simply traveling to an underdeveloped country does not significantly increase the risk of contracting hepatitis C.

A. Profuse vomiting with fecal odor B. Epigastric abdominal distention C. Intermittent abdominal cramping D. Ribbon-like stools or diarrhea E. Metabolic acidosis F. Severe fluid and electrolyte imbalance

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Choice A reason:Profuse vomiting with a fecal odor can occur in large bowel obstructions due to the backward flow of bowel contents.

Choice B reason:Epigastric abdominal distention is a common finding in bowel obstructions due to the accumulation of gas and fluids.

Choice C reason:Intermittent abdominal cramping results from the bowel's attempt to push contents through the obstructed area.

Choice D reason:Ribbon-like stools or diarrhea may occur if there is a partial obstruction allowing some contents to pass.

Choice E reason:Metabolic acidosis can develop due to the accumulation of lactic acid from tissue hypoxia and decreased perfusion.

Choice F reason:Severe fluid and electrolyte imbalance can result from vomiting and the inability to absorb fluids and nutrients properly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?

Correct Answer is C

Explanation

A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?

A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following clinical manifestations?

A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).

A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?