A nurse in an emergency department is caring for a client. History and Physical.
0400:.
57-year-old male client presents to the emergency department with severe abdominal and epigastric pain that began about 12 hr ago. Client rates pain as a 7 on a 0 to 10 pain scale. Client reports pain worsens after eating and radiates into his back. States is nauseous and has had several episodes of vomiting, i Reports some shortness of air and increased pain when lying । flat.
Client is alert and oriented x4 but appears ill. Sclera and palate noted to be yellow. Abdomen distended, rigid, and tender to palpation. Skin turgor poor.
Client reports consuming 3 to 4 alcoholic drinks per day, denies use of other substances. No known allergies.
0730:.
Will admit to medical-surgical unit for treatment of pancreatitis. Treatment plan discussed with client.
Vital Signs.
0330:.
Temperature 38.4° C (101.1 ° F). Heart rate 120/min.
Respiratory rate 24/min.
Blood pressure 100/66 mm Hg. SpO2 94% on room air.
: .
Temperature 38° C (100.4° F). Heart rate 106/min.
Respiratory rate 22/min.
Blood pressure 106/68 mm Hg.
SpO2 98% on O2 @ 2 L/min via nasal cannula. Nurses' Notes.
Day 1,0330:.
Client presents for evaluation of severe pain in upper abdomen that radiates into his back. States pain began approximately 12 hr ago and is worse when he is supine or after he eats. Rates pain as a 7 on a 0 to 10 pain scale. 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. Denies recent illnesses, takes no prescribed medications. Client is alert and oriented x 4.
Day 1,0800:.
Report provided to medical-surgical nurse. Client transferred to medical-surgical unit via gurney.
Laboratory Results [\. Day 1,0430:.
Amylase 640 units/L (30 to 220 units/L).
Lipase 220 units/L (0 to 160 units/L).
Bilirubin (total) 3.7 mg/dL (0.3 to 1 mg/dL).
Calcium 8.1 mg/dL (9 to 10.5 mg/dL). Glucose (casual) 215 mg/dL (< 200 mg/dL). Hemoglobin 20 g/dL (14 to 18g/dL).
Hematocrit 60% (42% to 52%).
WBC count 18,000/mm (5,000 to 10,000/mm). Platelet count 160,000/mm (150,000 to 400,000/mm).
The nurse is preparing to discharge the client. Which of the following statements by the client indicate an understanding of the discharge teaching?
Select all that apply.
"I will eat fish for dinner at least twice per week.".
"I will limit my morning coffee to no more than two cups.".
"I will eat small, frequent meals.".
"I should expect my bowel movements to be pale in color".
"I will notify my provider if my urine is dark.".
Correct Answer : C
C. “I will eat small, frequent meals.”.
This statement indicates an understanding of the discharge teaching because eating small, frequent meals can help reduce the workload of the pancreas and prevent pain and nausea.
A. “I will eat fish for dinner at least twice per week.” This statement does not indicate an understanding of the discharge teaching because fish is a high-fat food that can aggravate pancreatitis. The client should eat a low-fat diet with no more than 30 grams of fat per day.
B. “I will limit my morning coffee to no more than two cups.” This statement does not indicate an understanding of the discharge teaching because coffee is a caffeinated beverage that can stimulate the pancreas and worsen the inflammation. The client should avoid caffeine and alcohol.
D. “I should expect my bowel movements to be pale in color”. This statement does not indicate an understanding of the discharge teaching because pale stools can be a sign of bile duct obstruction or pancreatic insufficiency, which are complications of pancreatitis. The client should notify the provider if they notice any changes in their stool color or consistency.
E. “I will notify my provider if my urine is dark.” This statement does not indicate an understanding of the discharge teaching because dark urine can be a sign of dehydration or jaundice, which are also complications of pancreatitis. The client should drink plenty of fluids and monitor their skin and eyes for yellowing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","F"]
Explanation
Answer is… C and F indicate improvement.
A The client has gained 1.8 kg (4 lb). BMI is 18.9. This is not an improvement because the client’s BMI is still below the normal range of 18.5 to 24.9 The client may have malnutrition or other health problems that affect their weight.
B The clients adult child prepares two meals per day for the client. This is not an improvement because it shows that the client still depends on others for their basic needs and may have difficulty with self-care.
C The clients clothing is clean and appropriate for the weather. This is an improvement because it shows that the client has good hygiene and can dress themselves appropriately.
D The client receives three baths per week from a home care aide. This is not an improvement because it shows that the client still needs assistance with bathing and may have limited mobility or pain.
E The client reports frequent toothaches and lack of dental care. This is not an improvement because it shows that the client has poor oral health and may have infections or other complications.
F The client makes eye contact and smiles when speaking. This is an improvement because it shows that the client has positive mood and social interaction.
: https://www.hopkinsmedicine.org/health/conditions-and-diseases/distal-radius-fracture- wrist-fracture : https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.
Correct Answer is D
Explanation
The correct answer is choice D. Shuffling gait. This is because shuffling gait is a common manifestation of pseudoparkinsonism, which is a condition that mimics the symptoms of Parkinson’s disease due to the use of certain medications that block dopamine receptors, such as haloperidol. Pseudoparkinsonism can cause slowed movements, muscle stiffness, tremor, and postural instability.
Choice A. Nonreactive pupils is wrong because this is not a typical feature of pseudoparkinsonism or Parkinson’s disease.
Nonreactive pupils can be caused by other conditions, such as brain injury, drugs, or eye diseases.
Choice B. Serpentine limb movement is wrong because this is a characteristic of tardive dyskinesia, another drug-induced movement disorder that can result from long-term use of dopamine receptor blocking agents. Tardive dyskinesia causes involuntary movements of the face, tongue, and limbs that are often writhing or twisting.
Choice C. Smacking lips is wrong because this is also a sign of tardive dyskinesia, not pseudoparkinsonism. Smacking lips is one of the orofacial movements that can occur in tardive dyskinesia due to abnormal muscle contractions.
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