A client with acute pancreatitis is experiencing severe abdominal pain. Which additional finding would concern the nurse the most?
Nausea and vomiting
Low-grade fever
Tachycardia
Absent bowel sounds
The Correct Answer is C
Choice A reason: Nausea and vomiting are common in acute pancreatitis due to pancreatic inflammation causing gastrointestinal irritation and slowed gastric emptying. While uncomfortable and requiring management, they are expected symptoms and less immediately life-threatening than cardiovascular instability, as they do not directly indicate systemic complications like shock.
Choice B reason: Low-grade fever may occur in acute pancreatitis due to inflammation or early infection. It is concerning but not immediately critical unless persistent or high-grade, as it does not directly indicate systemic decompensation or organ failure, unlike cardiovascular changes that suggest hemodynamic instability.
Choice C reason: Tachycardia is highly concerning in acute pancreatitis, as it may indicate hypovolemia, shock, or systemic inflammatory response syndrome (SIRS) from pancreatic necrosis or fluid sequestration. Rapid heart rate reflects cardiovascular stress, requiring urgent intervention to stabilize circulation and prevent multi-organ failure, making it the most critical finding.
Choice D reason: Absent bowel sounds suggest ileus, a common complication of acute pancreatitis due to inflammation affecting gastrointestinal motility. While significant, it is less urgent than tachycardia, as it does not immediately threaten hemodynamic stability or indicate systemic complications like shock or organ failure, requiring supportive care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Increased thirst (polydipsia) is a symptom of hyperglycemia, not hypoglycemia, in type 1 diabetes. It results from osmotic diuresis due to elevated glucose, not low glucose levels, making it irrelevant for immediate intervention in a hypoglycemic crisis requiring rapid glucose administration.
Choice B reason: Tremors and sweating are classic signs of hypoglycemia in type 1 diabetes, caused by sympathetic nervous system activation and catecholamine release in response to low blood glucose. These indicate an urgent need for glucose to prevent seizures or unconsciousness, making this the priority symptom.
Choice C reason: Increased appetite (polyphagia) is associated with hyperglycemia, not hypoglycemia, as cells are starved of glucose due to insulin deficiency. It does not require immediate intervention in a hypoglycemic context, as it reflects a different metabolic state, making this symptom less urgent.
Choice D reason: Frequent urination (polyuria) is a hyperglycemia symptom, driven by osmotic diuresis from high glucose levels, not hypoglycemia. It does not indicate an acute crisis requiring immediate action, unlike tremors and sweating, which signal a potentially life-threatening low glucose state.
Correct Answer is C
Explanation
Choice A reason: Right shoulder pain post-laparoscopic cholecystectomy is not due to prolonged positioning. It results from carbon dioxide used to insufflate the abdomen, irritating the diaphragm and causing referred pain via the phrenic nerve, making this statement incorrect for explaining the pain’s origin.
Choice B reason: Nitrous dioxide is not used in laparoscopic cholecystectomy; carbon dioxide is the standard insufflation gas. This gas causes diaphragmatic irritation, leading to referred shoulder pain, not nitrous dioxide, making this statement factually incorrect regarding the cause of postoperative pain.
Choice C reason: Ambulation helps dissipate carbon dioxide gas trapped in the abdomen post-laparoscopic cholecystectomy, reducing diaphragmatic irritation and referred shoulder pain. Movement facilitates gas absorption and excretion via the lungs, alleviating discomfort, making this the correct nursing statement to relieve the patient’s pain.
Choice D reason: Residual pain from cholecystitis is unlikely post-cholecystectomy, as the gallbladder, the source of inflammation, is removed. Shoulder pain is due to surgical gas, not ongoing cholecystitis, making this statement incorrect for explaining the postoperative pain experienced by the client.
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