A client with suspected peptic ulcer disease suddenly reports severe abdominal pain, has a rigid, board-like abdomen, and complains of pain radiating to the shoulder. Which action should the nurse take first?
Provide a warm heating pad to the abdomen.
Notify the provider immediately.
Administer the prescribed antacid.
Reassess the abdomen in 60 minutes.
The Correct Answer is B
A. Provide a warm heating pad to the abdomen: Heat increases vasodilation and may worsen inflammation or bleeding in the setting of a suspected perforated ulcer. Thermal application can also mask worsening symptoms and delay urgent intervention. This measure is contraindicated in an acute abdominal emergency.
B. Notify the provider immediately: Sudden severe pain, a rigid board-like abdomen, and referred shoulder pain indicate possible gastric or duodenal perforation with peritonitis. This is a life-threatening surgical emergency requiring rapid medical and surgical intervention. Immediate provider notification is critical to prevent sepsis and shock.
C. Administer the prescribed antacid: Antacids reduce gastric acidity but do not address perforation or intra-abdominal contamination. Giving oral medications may be unsafe if surgical intervention is imminent. This action delays definitive care.
D. Reassess the abdomen in 60 minutes: Delaying action in the presence of classic signs of perforation risks rapid deterioration. Ongoing leakage of gastric contents can quickly lead to peritonitis and systemic infection. Immediate escalation of care is required rather than reassessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hyperthyroidism: Hyperthyroidism can cause weight loss, heat intolerance, and tachycardia, but it does not typically present with severe hyperglycemia, dehydration, or neurologic deficits. The clinical picture described is not consistent with thyroid overactivity.
B. HHS: Hyperosmolar Hyperglycemic State (HHS) occurs in type 2 diabetes and is characterized by extreme hyperglycemia, profound dehydration, and neurologic deficits such as confusion or lethargy, without significant ketone production. This matches the client’s presentation and is a medical emergency.
C. DKA: Diabetic Ketoacidosis primarily occurs in type 1 diabetes and presents with hyperglycemia, ketonemia, metabolic acidosis, and dehydration. The absence of significant ketones in this client makes DKA less likely.
D. Hypoglycemia: Hypoglycemia presents with low blood glucose and symptoms such as shakiness, sweating, confusion, or seizures. Severe hyperglycemia and dehydration are inconsistent with hypoglycemia.
Correct Answer is B
Explanation
A. Weight loss despite increased appetite: This finding is more consistent with hyperthyroidism, where increased metabolism leads to weight loss despite increased caloric intake. It is not typical in hypothyroidism.
B. Bradycardia and cold intolerance: Hypothyroidism slows metabolic processes, leading to a decreased heart rate (bradycardia) and sensitivity to cold due to reduced heat production. These are classic signs of underactive thyroid function.
C. Heat intolerance and sweating: These symptoms are associated with hyperthyroidism, where increased metabolism generates excess heat and promotes diaphoresis. They are inconsistent with hypothyroidism.
D. Exophthalmos and restlessness: Exophthalmos is a hallmark of Graves’ disease (hyperthyroidism), and restlessness reflects increased sympathetic activity. These are not typical manifestations of hypothyroidism.
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