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?

Nothing by mouth.

Electrocardiogram.

Monitor urinary output.

Complete bed rest.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis). Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.

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Correct Answer is A

Explanation

Choice A Reason:
Observing pupil size when focusing on a near object and then a far object is correct. This choice is correct because it directly assesses the pupillary reaction to accommodation, which refers to the changes in pupil size that occur when the eyes shift focus between near and far objects. Observing the pupils while the client focuses on a near object and then a far object allows the nurse to assess how the pupils constrict (become smaller) or dilate (become larger) in response to changes in focus, providing valuable information about the client's accommodation reflex.
Choice B Reason:
Comparing the shape of each of the pupils bilaterally with normal room light is incorrect. While comparing the shape of each pupil bilaterally with normal room light is a valid assessment technique for evaluating pupillary size and symmetry, it does not specifically assess the pupillary reaction to accommodation. Therefore, this choice is not as directly relevant to assessing accommodation reflex as choice A.
Choice C Reason:
Noting the speed of pupil constriction when a penlight is shined into the eye is incorrect. This choice refers to assessing the pupillary light reflex, which involves observing the speed and extent of pupil constriction in response to a bright light stimulus. While this assessment is important for evaluating the pupillary response to light, it does not specifically assess accommodation, which involves changes in pupil size in response to changes in focus between near and far objects. Therefore, this choice is not directly relevant to assessing accommodation reflex.
Choice D Reason:
Determining if dilation of the pupils occurs when the room is darkened is incorrect. This choice involves assessing the pupillary response to changes in ambient light levels, which is known as the pupillary light reflex. While assessing pupil dilation in response to darkness is important for evaluating the pupillary response to changes in light, it does not specifically assess accommodation reflex. Therefore, this choice is not directly relevant to assessing accommodation reflex.

A. Chronic pancreatitis. B. Peptic ulcer disease (PUD). C. Esophagitis. D. Gastroesophageal reflux (GERD).

Correct Answer is B

Explanation

Choice A Reason:
Chronic pancreatitis is incorrect. Chronic pancreatitis typically presents with persistent, dull abdominal pain that may radiate to the back, often aggravated by eating rather than relieved by it. The pain associated with chronic pancreatitis is not typically described as gnawing or relieved by eating.
Choice B Reason:
Peptic ulcer disease (PUD) is correct. Peptic ulcer disease involves the development of open sores (ulcers) in the lining of the stomach (gastric ulcers) or the upper part of the small intestine (duodenal ulcers). The pain associated with PUD typically occurs in the epigastric region (upper abdomen) and can be described as gnawing, burning, or dull. The pain tends to worsen when the stomach is empty (hunger pains) and is relieved by eating or taking antacids. These symptoms are due to the increase in gastric acid secretion, which exacerbates the ulcer's irritation when the stomach is empty and is neutralized when food buffers the acid. Therefore, the presentation described is consistent with peptic ulcer disease (PUD).
Choice C Reason:
Esophagitis is incorrect. Esophagitis is inflammation of the esophagus and may present with symptoms such as heartburn, difficulty swallowing, or chest pain behind the breastbone. However, the symptoms described, particularly the worsening of pain when hungry and improvement after eating, are not typical of esophagitis.
Choice D Reason:
Gastroesophageal reflux (GERD) is incorrect. While gastroesophageal reflux disease (GERD) can cause epigastric discomfort or heartburn, the symptoms described in the scenario are more indicative of pain related to hunger and relief after eating, which is more characteristic of peptic ulcer disease (PUD). Additionally, GERD symptoms are typically worsened by eating, lying down, or bending over, rather than improved.

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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

To assess a client's pupillary reaction to accommodation, what action should the nurse take?

Correct Answer is A

Explanation

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 B

Explanation

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

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