The nurse is caring for a client who has a history of peptic ulcer disease and is being admitted to the hospital with clinical manifestations of a perforation. Which finding by the nurse would best Indicate that perforation has occurred?
Numbness in the legs
Rebound tenderness on abdominal palpation
Projectile vomiting of undigested food
Jaundice of the skin and sclera
The Correct Answer is B
B. Rebound tenderness on abdominal palpation: Rebound tenderness, where pain increases upon release of pressure during abdominal palpation, is a classic sign of peritonitis, which can occur due to a peptic ulcer perforation. It indicates irritation of the peritoneum, the lining of the abdominal cavity, which can occur when stomach contents leak into the peritoneal cavity.
A. Numbness in the legs is not typically associated with perforation of a peptic ulcer. Perforation of a peptic ulcer usually presents with localized abdominal symptoms rather than symptoms in the legs.
C. Projectile vomiting of undigested food is not typically associated with perforation of a peptic ulcer. It is more commonly seen in conditions such as pyloric stenosis or gastrointestinal obstruction.
D. Jaundice, a yellow discoloration of the skin and sclera, is not typically associated with perforation of a peptic ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Before taking further action, the nurse should investigate whether there have been any changes in the client's diet, exercise routine, or lifestyle that may have contributed to the plateau in weight loss. Understanding any modifications made by the client can provide valuable insights into potential factors affecting their weight loss progress.
B. Bariatric surgery is a significant decision that requires careful consideration and evaluation of various factors. It is not appropriate to jump to this option without first exploring other potential reasons for the lack of weight loss.
C. While it's essential to review diet and exercise guidelines periodically to ensure the client is following appropriate recommendations, this option may not address the underlying cause of the recent lack of weight loss.
D. Regular weight monitoring is an important component of weight management and can provide valuable information about the client's progress. However, instructing the client to record weight weekly alone may not address the underlying reason for the lack of weight loss.
Correct Answer is ["A","B","D"]
Explanation
A. Daily weighing can help individuals monitor their progress and stay accountable for their weight loss goals. However, it's essential to emphasize that weight can fluctuate due to various factors such as hydration, digestion, and muscle mass changes, so the focus should be on overall trends rather than daily fluctuations.
B. Joining a support group can provide individuals with encouragement, motivation, and accountability during their weight loss journey. It allows them to connect with others who are facing similar challenges and share strategies for success.
D. Keeping a food diary or journal can be a valuable tool for promoting awareness of eating habits, tracking calorie intake, and identifying patterns or triggers for overeating. It helps individuals make informed choices about their diet and can contribute to successful weight loss by promoting accountability and mindfulness.
C. Use large, yellow plates is not typically included in successful weight loss strategies. Plate size and color may have minimal impact on food intake compared to factors such as portion control, food choices, and mindful eating practices.
E. Eating quickly and leaving the table can lead to overeating because it doesn't allow time for the body to register fullness signals.
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