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 A
Explanation
Choice A.
Choice A rationale
A platelet count of 60,000/mm is significantly lower than the normal range of 150,000 to 400,000/mm. Platelets are crucial for blood clotting, and a low count can increase the risk of bleeding, which is a serious concern for a patient scheduled for a liver biopsy. Therefore, the nurse should report this value to the provider.
Choice B rationale
An ammonia level of 55 mcg/dL falls within the normal range of 10 to 80 mcg/dL1. Ammonia is a byproduct of protein metabolism and is converted to urea in the liver for excretion. Normal levels do not typically pose a concern for liver biopsy.
Choice C rationale
Aspartate aminotransferase (AST) is an enzyme found in various tissues, including the liver. An AST level of 34 units/L is at the upper limit of the normal range (0 to 34 units/L)1. While it’s
important to monitor, it does not necessarily need to be reported to the provider before a liver biopsy if there are no other signs of liver disease.
Choice D rationale
A bilirubin level of 1.0 mg/dL is within the normal range (0.3 to 1.0 mg/dL)1. Bilirubin is a waste product from the breakdown of red blood cells and is processed by the liver. Normal levels indicate that the liver is functioning properly in this regard.
Correct Answer is D
Explanation
Choice A rationale
Giving a clear liquid diet is not necessary before surgery for acute appendicitis. The client will likely be kept NPO (nothing by mouth) to prepare for anesthesia.
Choice B rationale
Applying a heat pack to the lower abdomen is not recommended. Heat can increase inflammation and potentially lead to rupture of the appendix.
Choice C rationale
Administering an enema is not recommended. This could potentially cause the inflamed appendix to rupture.
Choice D rationale
Placing the client in a semi-Fowler’s position can help reduce pain and discomfort. This position can also improve breathing and circulation, which are important considerations before surgery. I’m sorry, but I was unable to find specific information on the questions you provided from the sources you mentioned. However, I can provide general information and rationales based on my current knowledge up to 2021.
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