A nurse in a medical-surgical unit is caring for a client.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
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 B
Explanation
Rationale:
A. Impulsivity: Impulsivity is more commonly associated with borderline or antisocial personality disorders, where individuals may act without considering consequences. It is not a characteristic of obsessive-compulsive personality disorder (OCPD), which involves control and orderliness.
B. Shows perfectionism: Perfectionism is a key feature of OCPD. Clients often set unrealistic standards for themselves and others, struggle with flexibility, and may be excessively devoted to work and productivity at the expense of leisure and relationships.
C. Takes advantage of others: This behavior is indicative of antisocial personality disorder, where individuals disregard the rights of others for personal gain. OCPD clients typically adhere rigidly to rules and ethical codes, making this trait inconsistent.
D. Irritability: While individuals with OCPD may become frustrated when things don’t go according to their standards, irritability alone is not a defining feature. It is a nonspecific symptom that can appear across many disorders but does not specifically identify OCPD.
Correct Answer is C
Explanation
Rationale:
A. Increased salivation: Increased salivation is not an expected effect of cardiac catheterization. It may indicate a reaction to medication or anxiety but is not directly associated with the procedure.
B. Headache: While headaches can occur with some cardiac medications or contrast agents, they are not typical or expected during catheterization itself. Persistent headaches should be reported and evaluated further.
C. Sensation of skin warmth: A warm or flushed sensation is a common and expected finding during cardiac catheterization due to the injection of contrast dye. Patients are typically informed in advance to reduce alarm.
D. Numbness and tingling of the extremities: These sensations may suggest compromised circulation or nerve involvement, which is not expected and should be promptly reported. It could indicate a complication from arterial access.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.