A client with acute pancreatitis presents with a board-like abdomen, guarding and absent bowel sounds. What should the nurse be most concerned about?

Pleural Effusion

Bowel obstruction

Pancreatic abscess

Paralyticleus

Answer and Explanation

The Correct Answer is C

Rationale:

A. While pleural effusion can occur in acute pancreatitis due to inflammation and fluid shifts, it typically presents with respiratory symptoms such as shortness of breath or decreased breath sounds. It does not directly cause a board-like abdomen, severe guarding, or absent bowel sounds.

B. Bowel obstruction can cause abdominal distention and absent bowel sounds, but it usually presents with colicky pain, vomiting, and sometimes constipation. A rigid, board-like abdomen and severe guarding suggest a more acute and dangerous intra-abdominal process.

C. A board-like abdomen, severe guarding, and absent bowel sounds are classic signs of peritonitis, which may result from a pancreatic abscess or rupture. This is a life-threatening complication of acute pancreatitis that requires immediate attention, often surgical intervention. The nurse should recognize these signs as an emergency.

D. Paralytic ileus can cause absent bowel sounds and abdominal distention, but it usually does not cause severe localized tenderness or a rigid, board-like abdomen. It is serious but less immediately life-threatening than peritonitis from a pancreatic abscess.

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Correct Answer is C

Explanation

Rationale:

A. Obtaining a type and crossmatch is necessary for blood transfusion in variceal bleeding, but this is not the immediate first action. Stabilizing the airway takes precedence over preparing for transfusion.

B. Inserting two large-bore IV lines is important for rapid fluid or blood replacement, but it comes after ensuring the airway is clear and the client can oxygenate effectively. IV access alone does not prevent hypoxia.

C. Suctioning the airway is the first priority. Clients with variceal bleeding are at risk for vomiting large amounts of blood, which can obstruct the airway and cause aspiration or hypoxemia. According to the ABC (Airway, Breathing, Circulation) priority framework, maintaining a patent airway is always the first action in emergencies.

D. Preparing the client for endoscopy is essential for definitive treatment of variceal bleeding, but this is not the immediate priority. The client must first be stabilized—airway maintained, breathing supported, and circulation ensured—before diagnostic or therapeutic procedures.

A. I enjoy my job: I should be able to return to work in about 4 to 8 weeks." B. I am planning on continuing to be active in the local town service club. C. "I have missed friends and look forward to having a glass of wine with them." D. "My spouse has been very supportive during my lengthy hospitalization."

Correct Answer is C

Explanation

Rationale:

A. This statement demonstrates that the client has a realistic expectation of recovery after an acute exacerbation of chronic pancreatitis. Typically, after an exacerbation, clients may need several weeks to regain strength and resume normal activities. The nurse does not need to change the teaching plan based on this statement, as it aligns with recovery guidelines.

B. Engagement in social and community activities supports emotional well-being and recovery. Continuing normal activities within the limits of physical tolerance is encouraged, and this statement indicates the client is planning to maintain a healthy social life. No modification of the teaching plan is necessary.

C. This statement raises a major concern because alcohol consumption is a primary risk factor for exacerbations of chronic pancreatitis. Even small amounts of alcohol can trigger inflammation, cause pain, or worsen pancreatic function. The nurse must intervene by revising the teaching plan to emphasize strict alcohol avoidance, discuss alternative ways to socialize without alcohol, and reinforce the importance of lifestyle modifications to prevent recurrent attacks. This statement indicates a knowledge gap or misunderstanding, making it the reason for changing the teaching plan.

D. Positive support systems, such as a caring spouse, enhance adherence to treatment recommendations and overall recovery. This statement reflects the client’s recognition of social support, which is beneficial for both physical and emotional recovery. No teaching changes are needed based on this comment.

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A client with acute pancreatitis presents with a board-like abdomen, guarding and absent bowel sounds. What should the nurse be most concerned about?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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