M. R. is a 52-year-old female who presents complaining of significant abdominal pain, which she rates as 8 to 9 on a 1 to 10 scale. The pain has been going on for a matter of hours, and she is afraid it wont go away on its own. She denies any nausea or vomiting, and she cannot remember precisely when her last bowel movement occurred probably it was a few days ago. She reports that she is always constipated. On physical examination, she is tachycardic but otherwise has normal vital signs her abdomen is tensely rigid, but no point tenderness to palpation is appreciated. The entire abdomen percusses as tympanicthere is no distinct dullness over the upper quadrants. Bowel sounds are present but hypoactive and intermittent. There is rebound tenderness to palpation. The AGACNP suspects

Correct Answer: B

Rationale: The patient's presentation with significant abdominal pain, tachycardia, tensely rigid abdomen, rebound tenderness, hypoactive and intermittent bowel sounds, and tympanic percussion of the entire abdomen is concerning for peritonitis. Peritonitis is inflammation of the peritoneum, which is the lining of the abdominal cavity. It is often caused by an infection or irritation, such as from a perforated bowel, which can lead to the leakage of bowel contents into the peritoneal cavity. The presentation of peritonitis includes severe abdominal pain, guarding, rebound tenderness, abdominal distension, and signs of systemic inflammation like tachycardia and fever. In this case, the lack of point tenderness to palpation and the absence of dullness over the upper quadrants make perforated bowel less likely, while the tense rigidity of the abdomen and rebound tenderness are more suggestive of diffuse peritonitis. Ischem

Correct Answer: A

Rationale: A leukocyte count of 18,000/µL suggests an elevated white blood cell count, which is indicative of an inflammatory or infectious process. In the context of biliary colic, an elevated white blood cell count could be a sign of complications such as cholecystitis (inflammation of the gallbladder) or choledocholithiasis (bile duct obstruction). These complications may require urgent surgical evaluation and intervention. The other options, although concerning, do not specifically suggest a complication that necessitates immediate surgical evaluation.

Correct Answer: C

Rationale: In this case, the best approach to the patient includes assessment of nonprostate causes of nocturia. Despite the lack of significant prostate hypertrophy on digital rectal examination, the patient is experiencing bothersome lower urinary tract symptoms such as nocturia, urinary urgency, and post-void dribbling. These symptoms suggest the need to consider alternative causes beyond prostate enlargement. Factors such as overactive bladder, urinary tract infections, diabetes, sleep apnea, medications, or other systemic conditions could be contributing to the patient's symptoms. Therefore, a comprehensive evaluation to identify potential nonprostate causes of the patient's nocturia is warranted before considering more invasive prostate-specific tests like PSA, ultrasound, or symptom scales.

Correct Answer: C

Rationale: When counseling a patient about surgical options for an ulcer that has been refractory to medical therapy, advising the patient that he will need some form of vagotomy is important. Vagotomy is a surgical procedure in which the vagus nerve is partially or completely severed. This procedure is commonly performed for patients with ulcers that have not responded to medical treatment. Vagotomy reduces the acid secretion in the stomach, which can help in the healing of the ulcer and prevent recurrence. It is an effective option for treating ulcers that have not responded to conservative medical management.

Correct Answer: C

Rationale: The Grey Turner sign is characterized by bruising in the flanks and is a rare finding associated with acute pancreatitis. It indicates retroperitoneal bleeding and is considered an ominous finding that suggests a severe and potentially moribund state in patients with acute pancreatitis. The presence of the Grey Turner sign should prompt immediate intervention and close monitoring in a hospital setting. The other options, severe epigastric pain with radiation to the back, abdominal guarding and rigidity, and obturator sign, are indicative of pancreatitis but do not carry the same ominous implication as the Grey Turner sign.