A 48-year-old man with a history cirrhosis secondary to hepatitis C presents to the emergency room with confusion, altered mentation, and erratic behavior. He is afebrile. His examination is notable for grossly normal motor strength throughout, hyperreflexia, asterixis, bulging flanks, and shifting dullness. His total bilirubin is 6 mg/dL, his creatinine is 1.8 mg/dL, and his prothrombin time is elevated. His white blood cell count is 11,000/µL with $85 \%$ neutrophils. His ammonia level is 30 µg/dL (normal 15-45 µg/dL). Which of the following statements is correct?

Correct Answer: B

Rationale: The correct answer is B. Ascitic fluid sampling is crucial in ruling out bacterial peritonitis in patients with cirrhosis presenting with altered mental status. The presence of ascites, bulging flanks, and shifting dullness in the patient's examination indicates ascites, which increases the risk of spontaneous bacterial peritonitis (SBP). SBP can lead to hepatic encephalopathy, contributing to the patient's altered mental status. Sampling ascitic fluid allows for culture and analysis to identify bacterial infection. Choice A is incorrect because normal ammonia levels do not exclude hepatic encephalopathy, which can still be present due to other factors. Choice C is incorrect as aminoglycosides are not recommended for empiric antibiotic therapy in SBP. Choice D is incorrect as lactulose is indicated for hepatic encephalopathy but not for treating bacterial peritonitis.

Correct Answer: B

Rationale: The correct answer is B: Constipation. Antacids containing aluminum or calcium can cause constipation due to their ability to slow down digestion. This is a common side effect observed in patients using antacids for peptic ulcer disease (PUD). Rationale: 1. Aluminum and calcium-based antacids can reduce bowel motility, leading to constipation. 2. Diarrhea is not a common side effect of antacids in the management of PUD. 3. Weight gain is not a direct side effect of antacids but may occur indirectly due to overeating to alleviate symptoms. 4. Dizziness is not a typical side effect of antacids in the management of PUD.

Correct Answer: B

Rationale: The correct answer is B because histamine-2 receptor antagonists (H2RAs) work by blocking the action of histamine on the H2 receptors of the stomach, which then leads to a decrease in gastric acid secretion. This helps in reducing the acidity level in the stomach, promoting ulcer healing in peptic ulcer disease (PUD). A: Neutralizing gastric acid is the action of antacids, not H2RAs. C: Coating the stomach lining is the mechanism of action of cytoprotective agents like sucralfate, not H2RAs. D: Eradicating H. pylori is a treatment approach for PUD caused by this bacterium, but H2RAs do not directly target H. pylori.

Correct Answer: D

Rationale: The correct answer is D (Both B and C). NSAIDs and aspirin are known to irritate the stomach lining and increase the risk of developing peptic ulcers. Acetaminophen, on the other hand, does not have the same effect on the stomach lining and is considered safer for patients with PUD. Therefore, advising a patient with PUD to avoid NSAIDs and aspirin is crucial to prevent exacerbation of the condition. Additionally, selecting option D is appropriate as it covers both medications that should be avoided, providing a comprehensive approach to managing PUD.

Correct Answer: C

Rationale: The correct answer is C: Perforated ulcer. The sudden, sharp, and persistent pain in the upper abdomen that worsens with movement is indicative of a perforated ulcer, where the stomach acid has eaten through the ulcer and leaked into the abdominal cavity. This can lead to severe pain and tenderness. Gastritis (choice A) typically presents with dull, aching pain. Intestinal obstruction (choice B) usually causes cramping abdominal pain with distension and vomiting. Pancreatitis (choice D) presents with severe, steady pain in the upper abdomen that may radiate to the back. Therefore, based on the sudden onset of sharp pain that worsens with movement in a patient with a history of PUD, the nurse should suspect a perforated ulcer.