A nurse in a medical-surgical unit is caring for a client.
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Nurses' Notes
Day 1, 0330:
Client presents for evaluation of severe pain in upper abdomen that radiates into their back. States pain began approximately 12 hr ago and is worse when they are supine or after they eat. Rates pain as 7 on a scale of 0 to 10. Sclera noted to be yellow. Heart rate regular, lungs clear to auscultation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday. Reports no recent illnesses takes no prescribed medications. Client is alert and oriented x4.
Client presents for evaluation of severe pain in upper abdomen that radiates into their back.
States pain began approximately 12 hr ago and is worse when they are supine or after they eat.
Rates pain as 7 on a scale of 0 to 10. Sclera noted to be yellow.
Heart rate regular, lungs clear to auscultation.
Abdomen firm, bowel sounds hypoactive.
Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday.
Reports no recent illnesses takes no prescribed medications.
Client is alert and oriented x4.
The Correct Answer is ["A","B","C","E","F"]
Rationale for Correct Choices:
- Pain radiating to the back, worsens after eating or lying down: This is characteristic of acute pancreatitis, where inflammation irritates surrounding tissues and worsens in the supine position due to gravitational pressure. Postprandial worsening suggests pancreatic enzyme stimulation.
- Scleral icterus (yellow sclera and palate): Jaundice suggests biliary obstruction or liver involvement, possibly due to gallstone pancreatitis or alcoholic liver disease. This also aligns with the elevated bilirubin levels and warrants further hepatic and biliary assessment.
- Abdomen distended, rigid, and tender with guarding: These are signs of peritonitis or severe intra-abdominal inflammation, requiring urgent evaluation. Guarding and rigidity indicate localized or diffuse peritoneal irritation from pancreatic enzymes.
- Hypoactive bowel sounds: Reduced bowel activity is often seen in pancreatitis due to paralytic ileus caused by inflammation and stress response. Monitoring for progression to ileus or obstruction is necessary.
- Client guards abdomen and grimaces during palpation: Guarding and pain upon palpation are signs of significant intra-abdominal inflammation. It may reflect worsening pancreatitis or complications such as necrosis or peritonitis.
Rationale for Incorrect Choices:
- Heart rate regular, lungs clear to auscultation: These are normal findings and do not require follow-up.
- Client is alert and oriented x4: Indicates normal neurologic status. No immediate concern here.
- Reports no recent illnesses, takes no prescribed medications: This helps rule out medication-induced pancreatitis and doesn't indicate a need for follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Wear a dosimeter film badge to measure exposure: A dosimeter badge tracks the cumulative radiation exposure for healthcare workers. It is essential for staff safety when caring for clients with internal radiation therapy.
B. Discard bed linens from the client's room at the end of each day: Linens should not be discarded unless contaminated. They are usually kept in the room until radiation is removed to avoid unnecessary exposure to other staff or areas.
C. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors should maintain a greater distance typically at least 6 feet (about 2 meters) and limit their visit time (usually to 30 minutes or less). Two feet is insufficient to minimize radiation exposure.
D. Place a caution sign on the client's door: Posting a radiation warning sign helps alert all personnel and visitors about radiation precautions, promoting safety and compliance with guidelines.
E. Don a lead apron when providing care: A lead apron protects the nurse from radiation exposure, especially when prolonged or close contact is necessary. It is a critical part of personal protective equipment in this setting.
Correct Answer is C
Explanation
Rationale:
A. Encourage the child to take naps during the day: While rest is important during flares, excessive daytime napping can contribute to stiffness and reduced physical function. Regular activity is encouraged to maintain joint mobility and overall well-being.
B. Apply splints to the child's extremities during the day: Splints may be used during sleep or periods of rest to reduce deformities, but wearing them during the day can interfere with play, physical therapy, and functional use of joints, which are important in school-age children.
C. Have the child take a tub bath each morning: Warm baths help relieve joint stiffness and pain, especially after nighttime immobility. Morning baths can promote flexibility, ease discomfort, and prepare the child for physical activity during the day.
D. Keep the child on bedrest as long as pain persists: Prolonged bedrest may worsen joint stiffness and muscle atrophy. Controlled physical activity is beneficial and helps prevent complications related to immobility. Pain management should support continued movement.
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