A nurse is caring for a 52-year-old male client in the emergency department. It’s now 0800hrs. The client reports worsening mid- abdominal pain, rating it as 8 on a scale of 0 to 10. He states, “I haven’t had a bowel movement in 5 days now.” He also mentions that he has vomited twice since the last assessment.
For each finding, specify if the finding is consistent with small bowel obstruction or acute pancreatitis. Each finding may support more than one disease process.
Abdominal Pain
No Bowel Movement for 5 days
Vomiting
Abdominal Distention
Increased Heart Rate
Elevated Temperature
Distention with fluid and gas in the small bowel (CT Scan)
Sodium: 130 mEq/L
Potassium: 3.3 mEq/L
WBC count: 10,000/mm
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"A,B"},"F":{"answers":"A,B"},"G":{"answers":"A"},"H":{"answers":"A,B"},"I":{"answers":"A,B"},"J":{"answers":"A,B"}}
- Abdominal Pain: Common in both small bowel obstruction and acute pancreatitis.
- No Bowel Movement for 5 days: More indicative of small bowel obstruction.
- Vomiting: Can occur in both conditions.
- Abdominal Distention: Seen in both small bowel obstruction and acute pancreatitis.
- Increased Heart Rate: Can be a response to pain or infection in both conditions.
- Elevated Temperature: Can occur in both conditions due to inflammation or infection.
- Distention with fluid and gas in the small bowel (CT Scan): Specific to small bowel obstruction.
- Sodium: 130 mEq/L: Hyponatremia can be seen in both conditions.
- Potassium: 3.3 mEq/L: Hypokalemia can be seen in both conditions.
- WBC count: 10,000/mm: Leukocytosis can be seen in both conditions due to inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Offering snacks that are high in sodium is not recommended for patients with heart failure. Sodium can cause fluid retention and worsen heart failure symptoms.
Choice B rationale
Monitoring the patient’s weight once per week is not sufficient for patients with heart failure. Daily weight monitoring is typically recommended to detect fluid retention early.
Choice C rationale
Providing rest periods throughout the day is recommended for patients with heart failure. Rest can help reduce the workload of the heart and manage symptoms of fatigue.
Choice D rationale
Placing the head of the patient’s bed flat is not recommended for patients with heart failure. This position can make breathing more difficult. Instead, the head of the bed should be elevated.
Correct Answer is A
Explanation
Comparing the current blood pressure reading to the preoperative value is the first step the nurse should take. This will help determine if the patient’s blood pressure has significantly dropped, which could indicate hypovolemia or shock.
Choice B rationale
Covering the patient with a warm blanket may be helpful if the patient is feeling cold or showing signs of hypothermia, but it would not address the underlying cause of the low blood pressure.
Choice C rationale
Increasing the IV flow rate might be necessary if the patient is hypovolemic, but this decision should be based on additional assessment data and physician orders.
Choice D rationale
Reassuring the patient is important, but it should not be the first action. The nurse needs to assess and address the cause of the low blood pressure.
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