During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Monitor urinary output.

Initiate NPO status.

Restrict activity to bed rest.

Obtain an electrocardiogram.

Answer and Explanation

The Correct Answer is B

A. Monitor urinary output. While important, this action does not address the acute abdominal pain.

B. Initiate NPO status. This is important to prevent aspiration and prepare for potential surgery or further diagnostic procedures, especially given the sign of possible peritonitis (Murphy's sign).

C. Restrict activity to bed rest. This may help but is not the immediate priority in managing acute abdominal pain and potential surgical emergency.

D. Obtain an electrocardiogram. This is not directly related to the abdominal symptoms described and may not address the immediate concern.

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Correct Answer is D

Explanation

A. Chronic pancreatitis. Chronic pancreatitis pain is often associated with eating and not relieved by food. Pain is typically more constant and can radiate to the back.

B. Gastroesophageal reflux (GERD). GERD typically causes heartburn and regurgitation, especially after eating, rather than pain that is relieved by eating.

C. Esophagitis. Esophagitis causes pain with swallowing and discomfort in the chest, not specifically relieved by eating.

D. Peptic ulcer disease (PUD). This is the best choice because PUD pain typically presents as gnawing or burning epigastric pain that is relieved by eating or taking antacids.

A. A 75-year-old with a pneumothorax and a chest tube. B. A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m2. C. A 2-year-old who is demonstrating diaphragmatic breathing. D. A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg).

Correct Answer is D

Explanation

A. A 75-year-old with a pneumothorax and a chest tube.With appropriate chest tube management and resolution of the pneumothorax, the PMI may return to its normal position. While this can be a valid challenge, it is transient and less likely to make PMI consistently difficult to locate.

B. A 45-year-old long-distance runner with a body mass index (BMI) of 18 kg/m2. Despite a low BMI, there are no factors here that would inherently make locating the PMI difficult.

C. A 2-year-old who is demonstrating diaphragmatic breathing. While diaphragmatic breathing is common in young children, it does not necessarily obscure the PMI.

D. A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg). This client is significantly obese, which can make it difficult to palpate and locate the PMI due to the excess adipose tissue.

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During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

Correct Answer is D

Explanation

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index [(BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

Correct Answer is D

Explanation

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