A client with acute pancreatitis has the following assessment: abdominal pain 7/10, nausea and vomiting for 2 days, vital signs: BP 108/70 mmHg, temperature 99.8°F, pulse 98 bpm, respiratory rate 22 breaths/min, inelastic skin turgor, and concentrated urine. Which nursing diagnosis should the nurse select as a priority?
Impaired elimination.
Fluid imbalance.
Fever.
Nausea.
The Correct Answer is B
Choice A reason: Impaired elimination may be a concern with pancreatitis due to potential complications affecting the gastrointestinal tract, but it is not the immediate priority.
Choice B reason: Fluid imbalance is the most critical issue in acute pancreatitis, as evidenced by inelastic skin turgor and concentrated urine, indicating dehydration, which can exacerbate the condition and lead to hypovolemic shock.
Choice C reason: Fever may be present due to inflammation or infection, but the temperature provided is not indicative of a significant fever and is not the priority over fluid imbalance.
Choice D reason: Nausea is a symptom of acute pancreatitis and while it needs to be managed, it is not the priority over fluid imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Needing a sweater or jacket is not typical for Graves' disease, which often causes intolerance to heat rather than cold.
Choice B reason: This response is typical for Graves' disease, as hyperthyroidism can increase metabolism, leading to feeling warm or hot even in cold weather.
Choice C reason: While temperature dysregulation can occur, the specific symptom of feeling warm in cold weather is more directly associated with Graves' disease.
Choice D reason: Cold fingers can be a symptom of many conditions, but it is not specifically indicative of Graves' disease.
Correct Answer is B
Explanation
Choice A reason: Petechiae are small red or purple spots caused by bleeding into the skin, typically associated with platelet disorders, and are not a direct indicator of SBP.
Choice B reason: Increased abdominal pain is a common symptom of SBP, as the condition causes inflammation and irritation of the peritoneum, which can lead to significant discomfort.
Choice C reason: Jaundice is a sign of liver dysfunction but is not specific to SBP. It results from high levels of bilirubin in the blood and can occur in various liver diseases.
Choice D reason: Blood in emesis (vomiting) may indicate gastrointestinal bleeding, which can be a complication of cirrhosis but is not specific to SBP.
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