A nurse is caring for a client diagnosed with peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?
Bradycardia
Hyperactive bowel sounds
Increased blood pressure
Sudden abdominal pain
The Correct Answer is D
A. Bradycardia is not typically associated with gastrointestinal perforation. Instead, tachycardia may be observed due to the body's response to a potential emergency or shock.
B. Hyperactive bowel sounds are not typically associated with gastrointestinal perforation. In fact, bowel sounds may decrease or become absent in severe cases of peritonitis or abdominal emergencies.
C. Increased blood pressure is not typically associated with gastrointestinal perforation. Hypotension may be observed due to hypovolemia resulting from fluid leakage into the peritoneal cavity.
D. Sudden abdominal pain is a key clinical manifestation of gastrointestinal perforation. The perforation of the stomach or intestines allows the contents to leak into the abdominal cavity, leading to peritonitis. Sudden and severe abdominal pain is a hallmark symptom, often described as sharp, stabbing, and constant.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Steatorrhea:
Steatorrhea refers to the presence of excessive fat in the stool. If a healthcare provider suspects malabsorption or fat digestion issues, they might order a fecal fat test to assess the amount of fat in the stool. This test is different from a guaiac fecal occult blood test (gFOBT), which is designed to detect blood.
B. Parasites:
The detection of parasites in the stool involves specific testing methods, such as microscopic examination of stool samples or specialized tests aimed at identifying the presence of parasitic organisms. A guaiac fecal occult blood test is not designed to detect parasites; its primary purpose is to identify occult (hidden) blood.
C. Blood:
A stool test for guaiac is specifically designed to detect the presence of occult (hidden) blood in the stool. The guaiac test involves placing a small sample of stool onto a test card containing guaiac, and a color change indicates the presence of blood. This test is commonly used to screen for gastrointestinal bleeding.
D. Bacteria:
Detecting bacteria in the stool typically involves stool cultures or specific tests designed to identify bacterial infections or imbalances in the gut microbiota. The guaiac test is not intended for detecting bacteria; its primary focus is on identifying the presence of blood in the stool.
Correct Answer is ["B","D","E"]
Explanation
A. Encourage weight lifting during physical therapy:
Encouraging weight lifting or strenuous physical activities might not be advisable for individuals with advanced cirrhosis. Engaging in intense physical activity could potentially strain the liver or increase the risk of injury or bleeding, which is already heightened in individuals with cirrhosis.
B. Measure the client's abdominal girth:
Monitoring the client's abdominal girth is essential because cirrhosis can lead to the accumulation of fluid in the abdomen, known as ascites. Changes in abdominal girth can indicate the progression or resolution of ascites, guiding treatment and interventions.
C. Administer warfarin:
Administering warfarin, an anticoagulant, might not be ideal in cirrhosis due to the increased risk of bleeding. Liver dysfunction in cirrhosis can impair the production of clotting factors, increasing the risk of bleeding complications.
D. Administer furosemide:
Furosemide, a diuretic, can be utilized in managing ascites by promoting the elimination of excess fluid. However, its use requires careful monitoring, considering the electrolyte balance and potential adverse effects, especially in individuals with liver impairment.
E. Implement a low-sodium diet:
A low-sodium diet is crucial in managing cirrhosis-related complications, particularly ascites and edema. Sodium restriction helps reduce fluid retention, lessening the burden on the liver and alleviating symptoms associated with fluid accumulation.
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