A client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for an oral temperature of 103°F (39.4°C) and an IV infusion of normal saline is initiated at 250 ml/hour. Which assessment finding should the nurse report to the healthcare provider immediately?

Petechial haemorrhage under client's eyes.

Right lower abdomen rebound tenderness.

Severe headache with photosensitivity.

Dark green coloured emesis.

Answer and Explanation

The Correct Answer is B

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

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Correct Answer is B

Explanation

Choice A reason: Amber urine is not unusual and can be related to dehydration. Although it should be monitored, it is not the most urgent finding in this scenario.

Choice B reason: Yellow sclera is a sign of jaundice, which occurs when there is a significant buildup of bilirubin in the blood. This is a critical indicator of a blocked bile duct and requires immediate medical attention to prevent severe complications.

Choice C reason: Flatulence is common with gastrointestinal disturbances but is not an urgent finding compared to jaundice.

Choice D reason: Belching is also common in digestive disorders and not as concerning as the presence of jaundice, which indicates a potentially serious problem with bile drainage.

A. Decrease foods high in fat or trans fats. B. Eliminate caffeine and chocolate. C. Augment intake of dairy products. D. Increase intake of insoluble fibber.

Correct Answer is D

Explanation

Choice A reason: Decreasing foods high in fat or trans fats is generally good for overall health, but it is not specifically related to managing diverticulosis. Focusing on fibber intake is more important for this condition.

Choice B reason: Eliminating caffeine and chocolate might be helpful for certain digestive issues, but it is not directly related to diverticulosis management. The primary concern for diverticulosis is to ensure adequate fibber intake to promote regular bowel movements and prevent complications.

Choice C reason: Augmenting the intake of dairy products is not directly beneficial for diverticulosis and could potentially cause discomfort in individuals who are lactose intolerant. It is not a recommended dietary modification for this condition.

Choice D reason: Increasing the intake of insoluble fibber is crucial for managing diverticulosis. Insoluble fibber helps to increase stool bulk and promote regular bowel movements, which can reduce the risk of diverticula formation and prevent flare-ups of diverticulitis. Foods rich in insoluble fibber include whole grains, vegetables, and fruits.

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Naxlex Comprehensive Predictor Exams

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

The nurse plans to provide diet instructions to a client who was recently diagnosed with diverticulosis. Which dietary modification should the nurse include in the teaching plan?

Correct Answer is D

Explanation

A female college student comes to the school's health clinic reporting urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

The nurse administers regular insulin SUBQ at 0700 to a client with type 1 diabetes mellitus (DM), after which the client eats one-half of the breakfast provided. At 1000, the client reports being hungry. Which action should the nurse implement?

The nurse is teaching the client about incentive spirometry in the preoperative unit. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

A client with hyperthyroidism tells the home health nurse, "I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding." Which assessment is most important for the nurse to obtain?

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide the client?