The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority?

Administer the prescribed pain medication.

Notify the health care provider immediately.

Percuss all four abdominal quadrants.

Take and document a set of vital signs.

Answer and Explanation

The Correct Answer is B

A. Administering pain medication may mask critical symptoms and delay diagnosis of a serious complication.
B. A sudden onset of sharp pain with a tense, rigid abdomen suggests possible perforation of the ulcer, a medical emergency requiring immediate intervention. The provider must be notified promptly.
C. Further assessment like percussion may delay emergency care and is not the priority in this scenario.
D. Vital signs are important but should be done concurrently or after notifying the provider, not before, as the situation is potentially life-threatening.

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Correct Answer is C

Explanation

A. Ribbon-like stools are typically associated with structural abnormalities such as Hirschsprung’s disease or rectal obstruction.

B. Hard, constipated stools are not characteristic of celiac disease, which more commonly causes diarrhea.

C. Bulky, frothy stools result from fat malabsorption (steatorrhea), which is a hallmark of untreated celiac disease due to damage to the intestinal villi.

D. While stools may be loose and foul-smelling, the more classic description is bulky and frothy due to unabsorbed nutrients and fats.

A. "The capsules can be opened and the powder sprinkled on applesauce if needed." B. "I will wipe my lips carefully after I drink the enzyme preparation." C. "The best time to take the enzymes is immediately after I have a meal or a snack." D. "I will not mix the enzyme powder with food or liquids that contain protein."

Correct Answer is C

Explanation

A. Enzyme capsules can be opened and the contents sprinkled on soft, acidic foods like applesauce to aid in swallowing.

B. Wiping the lips helps prevent skin irritation from the enzymes.

C. This indicates a need for further teaching. Enzymes should be taken with meals or immediately before eating—not after—so they can mix properly with food in the digestive tract.

D. Enzyme powder should not be mixed with protein-containing foods or liquids, as it may break down the proteins before ingestion.

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The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority?

Nursing Test Bank

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