A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)
Diarrhea.
Black tarry stools.
Hyperactive bowel sounds.
Gray-blue color at the flank.
Abdominal guarding and tenderness.
Left upper quadrant pain with radiation to the back.
Correct Answer : D,E,F
Choice A reason: Diarrhea is less common in acute pancreatitis, which typically causes nausea and vomiting. Flank discoloration is a specific sign, making this incorrect, as it’s not a primary finding the nurse would expect in the assessment of acute pancreatitis.
Choice B reason: Black tarry stools indicate upper GI bleeding, not pancreatitis, which causes pain and guarding. Left quadrant pain is typical, making this incorrect, as it’s unrelated to the nurse’s expected findings in a client with suspected acute pancreatitis.
Choice C reason: Hyperactive bowel sounds suggest obstruction, not pancreatitis, which often causes hypoactive sounds due to inflammation. Abdominal tenderness is correct, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in acute pancreatitis assessment.
Choice D reason: Gray, including its reasoning, and a gray-blue flank (Cullen’s or Grey Turner’s sign) indicates severe pancreatitis with hemorrhage. This aligns with severe pancreatitis assessment, making it a correct finding the nurse would expect in suspected acute pancreatitis.
Choice E reason: Abdominal guarding and tenderness result from pancreatic inflammation, common in acute pancreatitis. This aligns with abdominal assessment findings, making it a correct manifestation the nurse would identify in a client with suspected acute pancreatitis.
Choice F reason: Left upper quadrant pain radiating to the back is classic in acute pancreatitis due to pancreatic inflammation. This aligns with clinical assessment, making it a correct finding the nurse would expect in a client with suspected acute pancreatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Nausea and vomiting may occur with nitroglycerin, but depression, fatigue, and impotence are unrelated. Headache and hypotension are primary effects, making this incorrect, as it includes irrelevant symptoms compared to the nurse’s teaching on nitroglycerin’s expected side effects.
Choice B reason: Sedation, constipation, and respiratory depression are opioid effects, not nitroglycerin, which causes vasodilation. Dizziness and flushing are correct, making this incorrect, as it misattributes opioid side effects to nitroglycerin in the nurse’s education for angina management.
Choice C reason: Nitroglycerin causes headache, hypotension, dizziness, and flushing due to vasodilation, common side effects. This aligns with pharmacological education for angina, making it the correct set of symptoms the nurse would teach the client to expect after taking sublingual nitroglycerin.
Choice D reason: Pedal edema is not a nitroglycerin side effect, though flushing, dizziness, and headache are. Hypotension is more precise than edema, making this incorrect, as it includes an unrelated symptom compared to the accurate side effects in nitroglycerin teaching.
Choice E reason: Decreased cardiac output and peripheral edema are not nitroglycerin effects; it improves coronary flow. Flushing is correct, but hypotension is key, making this incorrect, as it misrepresents nitroglycerin’s pharmacological effects in the nurse’s teaching for angina relief.
Correct Answer is B
Explanation
Choice A reason: Unprotected sex is a risk for hepatitis B or C, not A, which is fecal-oral. Shellfish consumption is a common source, making this incorrect, as it doesn’t support the nurse’s diagnosis of hepatitis A based on the client’s history.
Choice B reason: Eating contaminated shellfish is a common cause of hepatitis A, transmitted via the fecal-oral route, with symptoms appearing 2-6 weeks later. This aligns with the diagnosis, making it the correct statement supporting the client’s hepatitis A diagnosis.
Choice C reason: Sharing needles spreads hepatitis B or C, not A, which is foodborne. Shellfish is a hepatitis A source, making this incorrect, as it’s unrelated to the nurse’s evaluation of the client’s flu-like symptoms and jaundice.
Choice D reason: Blood transfusions before 1992 risked hepatitis C, not A, which is fecal-oral. Eating shellfish supports hepatitis A, making this incorrect, as it doesn’t align with the nurse’s diagnosis based on the client’s jaundice and flu-like symptoms.
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