A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications?

5% deficit in body weight compared to pre-illness weight and increased caloric need.

Significant risk of aspiration coupled with decreased level of consciousness.

Calorie deficit and muscle wasting combined with low electrolyte levels.

Inability to take in adequate oral food or fluids within 7 days.

Answer and Explanation

The Correct Answer is D

Choice A rationale

A 5% deficit in body weight and increased caloric need alone do not warrant the initiation of parenteral nutrition (PN). PN is typically reserved for situations where oral or enteral feeding is not feasible or safe.

Choice B rationale

Significant risk of aspiration and decreased level of consciousness may necessitate alternative feeding methods, such as enteral feeding via a nasogastric or gastrostomy tube. PN is considered when enteral feeding is not possible.

Choice C rationale

Calorie deficit, muscle wasting, and low electrolyte levels indicate malnutrition, but PN is initiated when other feeding methods are inadequate or unsafe.

Choice D rationale

Inability to take in adequate oral food or fluids within 7 days is a clear indication for initiating PN. This ensures the patient receives essential nutrients and prevents further deterioration of their nutritional status.

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Correct Answer is D

Explanation

Choice A rationale

Administering a bolus of normal saline addresses fluid volume but does not directly address the respiratory effort increase or potential increased ICP, which is the most concerning aspect of the head injury.

Choice B rationale

Administering bronchodilators and monitoring LOC may help with respiratory issues but does not address the underlying problem of increased ICP, which could be causing the increased respiratory effort.

Choice C rationale

Increasing the client's bed height and reassessing in 30 minutes might temporarily help, but it is not the most immediate and appropriate intervention. The client’s symptoms suggest a more urgent issue.

Choice D rationale

Informing the care team and assessing for further signs of increased ICP is crucial. Increased respiratory effort in a client with head injury can indicate rising intracranial pressure, which requires immediate medical attention to prevent further complications.

A. Scoliosis. B. Lordosis. C. Kyphosis. D. Dowager's hump. E. Dowager's hump.

Correct Answer is B

Explanation

Choice A rationale

Scoliosis refers to a lateral curvature of the spine, not an exaggeration of the lumbar spine curve, which is characterized by lordosis.

Choice B rationale

Lordosis is an exaggerated inward curve of the lumbar spine, often referred to as swayback. This condition is identified by the nurse as the client presents with an exaggerated lumbar curve.

Choice C rationale

Kyphosis describes an excessive outward curvature of the thoracic spine, resulting in a hunched back, not the lumbar spine.

Choice D rationale

Dowager's hump is a term commonly associated with kyphosis, characterized by a pronounced curvature of the upper back, not the lumbar region.

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A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

Correct Answer is D

Explanation

The client presents with an exaggeration of the lumbar spine curve. How does the nurse interpret this finding?

Correct Answer is B

Explanation

A nurse's assessment of a teenage client reveals that their shoulders are not level and that they have one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the client's electronic health record?

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The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

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