A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?
Increased blood pressure
Hyperactive bowel sounds
Bradycardia
Sudden abdominal pain
The Correct Answer is D
Choice A reason:
Increased blood pressure is not typically associated with gastrointestinal perforation; hypotension may be more indicative.
Choice B reason:
Hyperactive bowel sounds may be present in various gastrointestinal conditions, but they are not specific to perforation.
Choice C reason:
Bradycardia is not a typical sign of gastrointestinal perforation; tachycardia may be more indicative of this condition.
Choice D reason:
This statement is correct. Sudden abdominal pain is a key indication of gastrointestinal perforation, and it should be monitored closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.
Choice B reason:
Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.
Choice C reason:
This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.
Choice D reason:
Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.
Correct Answer is C
Explanation
Choice A reason:
A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.
Choice B reason:
A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.
Choice C reason:
A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.
Choice D reason:
Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.
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