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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Providing oral care every 4 hours and as needed is an evidence-based practice to lower the risk of ventilator-associated pneumonia by minimizing the buildup of bacteria in the mouth³.
Choice B reason:Positioning the head of the client's bed in the flat position is not recommended as it can increase the risk of aspiration; elevating the head of the bed to 30° to 45° is the standard practice.
Choice C reason:Turning the client every 4 hours is important for preventing pressure ulcers and improving lung function but is not the primary action for reducing pneumonia risk³.
Choice D reason:Providing humidity helps to maintain mucous membrane integrity but must be carefully managed to prevent bacterial growth and is not the primary action for reducing pneumonia risk³.
Correct Answer is ["1.2"]
Explanation
- Step 1: Identify the child's weight in pounds. The child weighs 33 lbs.
- Step 2: Convert the child's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 33 lbs = 33 ÷ 2.2 kg. Calculating the division gives us approximately 15 kg.
- Step 3: Identify the prescribed dose in mcg/kg/day. The child is scheduled to receive 8 mcg/kg/day of digoxin, divided equally every 12 hours.
- Step 4: Calculate the total daily dose in mcg. We can do this by multiplying the child's weight in kg by the prescribed dose in mcg/kg:
- Total daily dose = 8 mcg/kg/day × 15 kg.
- Calculating the multiplication gives us: Total daily dose = 120 mcg/day.
- Step 5: Since the dose is divided equally every 12 hours, we divide the total daily dose by 2 to get the dose per administration:
- Dose per administration = Total daily dose ÷ 2.
- Dose per administration = 120 mcg ÷ 2.
- Calculating the division gives us: Dose per administration = 60 mcg.
- Step 6: Identify the concentration of the available solution. The available solution contains 0.05 mg/mL of digoxin. Convert this to mcg/mL for consistency with the dose per administration. We know that 1 mg = 1000 mcg. So, 0.05 mg = 0.05 × 1000 mcg = 50 mcg/mL.
- Step 7: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 50 mcg is to 1 mL as 60 mcg is to X mL.
- In other words, 50 mcg : 1 mL = 60 mcg : X mL.
- Step 8: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 50 mcg × X mL = 60 mcg × 1 mL.
- Simplifying this gives us: 50X = 60.
- Dividing both sides by 50 gives us: X = 60 ÷ 50.
- Calculating the division gives us: X = 1.2.
Administer 1.2 mL of the digoxin elixir per dose.
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