Correct answer—A. Rationales: A client with undiagnosed abdominal pain should receive nothing by mouth in case surgery is required. Obtaining a urine specimen and a CBC can help diagnose the cause of abdominal pain. Repositioning can sometimes diminish the client’s pain.

Nursing process step: Intervention

Correct answer—C. Rationales: Intestinal perforation is associated with free air under the diaphragm. Intestinal obstruction, acute appendicitis, and acute cholelithiasis aren’t associated with free air.

Nursing process step: Assessment

Correct answer-B. Rationales: The client with intestinal perforation will require surgery and should receive nothing by mouth. An NG tube should be inserted to decompress the GI tract. Antibiotics should be administered I.V. to prevent sepsis, which can be caused by leakage from the perforation.

Nursing process step: Implementation

Correct answer-C. Rationales: A major complication of pancreatitis is hypovolemia. Because hypovolemia can cause low blood pressure, orthostatic hypotension is associated with hypotension. Sharp, knifelike pain is expected and will be treated, but circulation takes priority. Bluish discoloration around the umbilicus (Cullen’s sign) is a result of the exudate from autodigestion of the pancreas in pancreatitis and does not require immediate intervention. One episode of emesis doesn’t require intervention.

Nursing process step: Analysis

Correct answer-C. Rationales: The three major complications of pancreatitis include hypovolemia (not hypervolemia), latent hypocalcemia (not hypercalcemia), and latent hypoxia.

Nursing process step: Analysis

Correct answer-C. Rationales: A distended bladder is an absolute contraindication for peritoneal lavage. Peritoneal lavage involves the instillation and withdrawal of fluid from the abdominal cavity. An indwelling urinary catheter should be inserted before the procedure. Radiopaque dye isn’t required. Peritoneal lavage is especially useful for diagnosing abdominal injuries in an unconscious client because he can’t report pain. A history of abdominal surgery isn’t a contraindication for this procedure.

Nursing process step: Intervention

Correct answer-B. Rationales: A highly vascular and encapsulated organ, the spleen is compressed against the vertebral column during blunt abdominal trauma. Injuries to the spleen are commonly seen in clients with left lower rib injuries. Injuries to the liver are common in clients with right lower rib fractures. The large bowel and stomach are seldom injured in blunt abdominal trauma.

Nursing process step: Assessment

Correct answer—C. Rationales: Because children younger than age 9 are abdominal breathers, chest movements are normally synchronized with abdominal movements. Failure of the abdomen to move with respirations could indicate serious abdominal injury. The high-pitched tympanic sounds indicate air in the stomach, a condition common in mouth breathers. Young children have a spinal lordosis that gives the abdomen a cylindrical, prominent contour. They may express their fear by crying during the examination; speaking softly and allowing a caregiver to stay nearby may help ease their fear.

Nursing process step: Assessment

Correct answer—C. Rationales: Small-bowel obstructions are higher and tend to lead to reverse peristalsis and emesis of feculent material. Dark, tarry stool is a classic symptom of upper GI bleeding, not obstruction. Normal bowel sounds consist of clicks and gurgles that occur at a rate of 5 to 30 per minute, so this is a normal finding. Bowel sounds are also more indicative of a large-intestine obstruction. The presence of a metallic taste isn’t related to a bowel obstruction.

Nursing process step: Analysis

Correct answer-B. Rationales: Coffee-ground emesis results from upper GI bleeding that has remained in the stomach. Upper GI bleeding is commonly caused by regular intake of NSAIDs. The client’s most recent food intake won’t help determine the cause of the client’s symptoms. Iron supplements could cause abdominal pain from constipation but not coffee-ground emesis. A history of hemorrhoids would cause recent bleeding, not coffee-ground emesis or abdominal pain.

Nursing process step: Analysis

Correct answer—D. Rationales: Albumin decreases because the liver can’t synthesize blood proteins. PT increases because the diseased liver can’t make clotting factors in sufficient amounts. These clients are prone to bleeding.

Nursing process step: Assessment

Correct answer-D. Rationales: These are classic symptoms of pyloric stenosis caused by hypertrophy of the circular pylorus muscle. Surgery is the standard treatment for this disorder. Abdominal masses and abnormal peristalsis aren’t necessarily related to colic or failure to thrive. Intussusception is usually characterized by acute onset and severe abdominal pain.

Nursing process step: Assessment

Correct answer-B. Rationales: The FAST test is a focused assessment sonography for trauma ultrasonography. It is a bedside, rapid, accurate diagnostic tool to detect the presence of hemoperitoneum. Four areas are examined: the hepatorenal fossa, the splenorenal fossa, the pericardial sac, and the pelvis. It isn’t a fecal assay screening test, nor does it determine whether free air is present or whether a bladder injury has occurred.

Nursing process step: Analysis

Correct answer-B. Rationales: Diverticulitis is one of the most common causes of acute abdominal pain in the geriatric population. About 50 % of all Americans from ages 60 to 80 have diverticulitis, as do most Americans over age 80. Inflammatory bowel disease is more common in clients aged 10 to 30. Bowel obstructions are commonly caused by adhesions from previous surgeries, fecal impaction, or tumors—not intussusception—in this population. Ulcerative colitis is more prevalent in clients aged 30 to 50.

Nursing process step: Assessment

Correct answer—D. Rationales: Excessive vomiting, which reduces hydrochloric acid in the stomach, causes metabolic alkalosis. It also leads to hypokalemia. Clients with the above symptoms would not be prone to acidosis or hyperkalemia.

Nursing process step: Assessment

Correct answer—C. Rationales: Before a client goes home, the client must be able to take and keep oral fluids so no dehydration occurs at home. Antidiarrheal medications aren’t routinely used for gastroenteritis. Repeating the BRAT diet requirements or hearing normal bowel sounds isn’t as important as the ability to tolerate oral fluids.

Nursing process step: Intervention

Correct answer-B. Rationales: The client with a stomach injury may have blood in the NG aspirate as well as epigastric pain and tenderness. Bowel sounds may be decreased or absent. Signs of peritonitis may be present if acidic gastric contents have been released. Bowel sounds in the chest are indicative of diaphragmatic rupture, not stomach injury.

Nursing process step: Evaluation

Correct answer—A. Rationales: Ecchymosis in the flank area (known as Turner’s sign) suggests retroperitoneal bleeding and is commonly associated with pancreatic injury. Dullness in the flank area (Ballance’s sign) is characterized by two types of dullness: a fixed dullness to percussion in the left flank and a dullness in the right flank that disappears with a change in position. Ballance’s sign is usually associated with splenic injuries. Option C is associated with liver injuries; option D is associated with colon injuries. A client with pancreatic injury may also demonstrate ileus, epigastric pain radiating to the back or left upper quadrant, a positive Kehr’s sign (pain in the left shoulder secondary to diaphragmatic irritation by blood), and pain, nausea, and vomiting.

Nursing process step: Assessment

Correct answer-B. Rationales: Decreased or absent bowel sounds may be caused by an irritant, such as blood or intestinal contents, outside the bowel. Irritants inside the bowel usually cause hyperactive bowel sounds. Hypovolemia and anxiety don’t cause decreased or absent bowel sounds.

Nursing process step: Evaluation

Correct answer-B. Rationales: The appearance of entrance and exit wounds doesn’t reflect the extent of internal injury; for example, a bullet may fragment and change direction once inside the body. Death occurs more commonly after blunt abdominal trauma, in which case external signs of injury aren’t obvious; therefore, detection and treatment may be delayed. Impaled objects shouldn’t be removed—instead, these objects should be stabilized with a dressing to prevent further injury to the client.