A nurse is caring for a client who has acute pancreatitis.
Vital Signs
Day 2:
Heart rate: 92/min
Respiratory rate: 20/min
BP: 122/58 mm Hg
Oxygen saturation: 96% on room air
Nurses Notes:
Oriented to person, place, and time; reports extreme fatigue.
Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago.
S1, S2 noted on auscultation. Pulses palpable.
Respirations even, unlabored. Chest clear on auscultation.
Bowel sounds hypoactive in all four quadrants. Client vomiting brown liquid and reports continuing nausea. Reports passing flatus. Urinating without difficulty, urine is clear yellow.
Heart rate: 92/min
Respiratory rate: 20/min
Oxygen saturation: 96% on room air
reports extreme fatigue.
Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago.
Respirations even, unlabored. Chest clear on auscultation.
Bowel sounds hypoactive in all four quadrants.
Client vomiting brown liquid and reports continuing nausea.
Reports passing flatus. Urinating without difficulty, urine is clear yellow.
The Correct Answer is ["A","B","C","E","F","I"]
-
Heart rate: 92/min: Improved from 109/min on Day 1, showing better autonomic control.
A heart rate within normal range indicates reduced stress or inflammation. This suggests pain management and fluid status have improved. -
Respiratory rate: 20/min: Improved from 26/min, now within normal limits. This reflects decreased respiratory effort and better oxygenation. The labored breathing on Day 1 has also resolved.
-
Oxygen saturation: 96% on room air: Increased from 93% on Day 1, indicating improved gas exchange. No supplemental oxygen was required, suggesting stable pulmonary function.
This is a positive sign especially given the initial diminished breath sounds. -
Client rates pain as 3/10 after medication: The pain is down from 8/10 on Day 1, showing effective analgesia. Pain control improves patient comfort and respiratory status. The pain was likely contributing to tachypnea and lethargy on Day 1.
-
Respirations even and unlabored; chest clear on auscultation: Improved from "rapid, labored" with "diminished" breath sounds on day 1 which suggests resolution of respiratory compromise and pain-related restriction. Likely associated with improved oxygen saturation and decreased fatigue..
-
Passing flatus: This indicates return of peristalsis and some bowel activity. These findings were not present on Day 1, showing progress. Flatus passage often precedes return to full bowel function.
-
Urinating without difficulty; urine clear yellow: These findings indicate stable renal function, no hematuria or concentration issues. The findings were maintained across both days, with no signs of obstruction or dehydration which uggests effective fluid balance and kidney perfusion.
Rationale for Incorrect Findings:
-
Bowel sounds hypoactive in all quadrants: No change from Day 1, suggests slow GI recovery. Hypoactivity may reflect paralytic ileus or continued inflammation.
Despite passage of flatus, bowel function remains impaired. -
Client vomiting brown liquid and reports continuing nausea: This is a new symptom on Day 2, worsening GI symptoms despite earlier improvement. Brown emesis may suggest delayed gastric emptying or possible GI bleeding.
-
Reports extreme fatigue: Fatigue is more severe than Day 1's lethargy and may reflect nutritional deficits, systemic inflammation, or sleep disruption. Despite improved pain and respiratory status, overall energy is low.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Androgens (sex hormones): These are produced in the zona reticularis of the adrenal cortex. They contribute to the development of secondary sex characteristics and have a minor role compared to gonadal hormones.
B. Glucocorticoids (cortisol): Cortisol is synthesized in the zona fasciculata of the adrenal cortex. It regulates metabolism, immune responses, and the stress response, making it a key adrenal cortical hormone.
C. Epinephrine: This hormone is produced by the adrenal medulla, not the cortex. It plays a major role in the fight-or-flight response, increasing heart rate and blood glucose levels during stress.
D. Mineralocorticoids (aldosterone): Aldosterone is produced in the zona glomerulosa of the adrenal cortex. It is essential for sodium retention, potassium excretion, and blood pressure regulation.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. May be idiopathic: In many cases, especially central precocious puberty, no identifiable underlying cause is found. This is referred to as idiopathic precocious puberty and is a common diagnosis, particularly in girls.
B. Peripheral precocious puberty is independent of gonadotropin release from the pituitary gland: Peripheral (or gonadotropin-independent) precocious puberty occurs due to hormone secretion from sources other than the pituitary, such as adrenal tumors or ovarian cysts.
C. Central precocious puberty is caused by premature activation of the hypothalamic-pituitary-gonadal (HPG) axis: This is the most common form and involves early activation of the normal puberty pathway via the HPG axis.
D. It is defined as the onset of secondary sexual characteristics before age 8 in girls and age 9 in boys: This is the widely accepted medical definition of precocious puberty based on chronological age for the appearance of secondary sexual characteristics.
E. Tall stature during childhood is a common feature, but final adult height may be shorter than expected without treatment: Early growth spurts can lead to early closure of growth plates, resulting in reduced adult height if untreated.
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.