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 C
Explanation
Rationale:
A. Institutional policies and procedures: While helpful in guiding facility-specific protocols, policies do not override state regulations. An institution may allow tasks that exceed or fall short of legal scope, so this should not be the primary reference.
B. Written prescription from the provider: A provider’s order does not define or expand a nurse’s legal scope of practice. Even with a valid order, the nurse must independently verify whether they are legally permitted to carry out the task.
C. State Nurse Practice Act: The Nurse Practice Act (NPA) is the legal authority that defines what licensed nurses are permitted to do in their state. It is the most authoritative resource to determine whether a task is within the nurse’s legal scope of practice.
D. Verbal direction from the nurse manager: Even when given by a superior, verbal instructions must still comply with state law. A nurse manager’s guidance cannot authorize a task that lies outside the nurse’s legal scope.
Correct Answer is A
Explanation
Rationale:
A. Provide humidification of the room air: Xerostomia, or dry mouth, often results from radiation therapy to the head and neck region. Humidifying room air adds moisture to the environment, helping relieve oral dryness and improving comfort, especially during sleep.
B. Suggest rinsing his mouth with an alcohol-based mouth wash: Alcohol-based mouthwashes can worsen oral dryness and irritate mucosal tissues, making xerostomia more uncomfortable. Clients should instead use alcohol-free or moisturizing rinses.
C. Instruct the client on the use of esophageal speech: Esophageal speech is a communication method taught to clients after laryngectomy, not for xerostomia. It does not address dry mouth and is unrelated to the effects of mandibular radiation.
D. Offer the client saltine crackers between meals: Saltine crackers are dry and salty, which can exacerbate oral dryness and discomfort. Clients with xerostomia benefit more from moist, soft foods and frequent sips of water.
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.