A nurse is caring for a patient with Systemic Lupus Erythematosus (SLE). The nurse would ask the validity of this sign or symptom listed in the patient's chart, as it is not typically seen in SLE:

Choice A rationale

Malnourishment occurs because the pancreas fails to secrete essential digestive enzymes like lipase and amylase into the duodenum. This leads to malabsorption of fats, proteins, and carbohydrates. Chronic inflammation or acute necrotizing processes damage acinar cells, preventing the breakdown of nutrients. Patients often lose weight rapidly due to this secondary nutritional deficiency. Serum albumin levels, normally 3.4 to 5.4 g/dL, may drop significantly as protein synthesis and absorption are impaired during the inflammatory response.

Choice B rationale

Acute pain is a primary complication resulting from the autodigestion of pancreatic tissue by prematurely activated enzymes like trypsin. This process causes severe mid-epigastric pain that often radiates to the back. The inflammation triggers the release of kinins and other inflammatory mediators that sensitize nociceptors. Distention of the pancreatic capsule and chemical peritonitis from leaked enzymes further intensify this sensation. Managing this pain is crucial to reduce the metabolic demand on the already stressed organ.

Choice C rationale

Peripheral edema is generally not a direct, immediate complication of acute pancreatitis compared to systemic issues like third-spacing or hypovolemia. While low albumin could eventually cause it, the more pressing concern is the shift of fluid into the peritoneal cavity or retroperitoneal space. Generalized swelling of the extremities is less common than localized inflammation or systemic shock. Therefore, it is not a prioritized complication that determines the immediate plan of care for most acute cases.

Choice D rationale

Nausea and vomiting are frequent complications caused by paralytic ileus or the intense pain associated with pancreatic inflammation. The inflammatory process can irritate the stomach and duodenum, leading to gastric stasis. This results in significant fluid and electrolyte imbalances. Frequent emesis can lead to metabolic alkalosis. It is vital to manage these symptoms with antiemetics and nasogastric suctioning to decompress the stomach and rest the pancreas by preventing further stimulation of digestive enzymes.

Choice E rationale

Dehydration is a critical complication resulting from massive fluid shifts, vomiting, and decreased oral intake. Inflammatory mediators increase capillary permeability, causing protein-rich fluid to leak into the interstitial and peritoneal spaces, known as third-spacing. This can lead to hypovolemic shock if not corrected with aggressive intravenous fluid resuscitation. Monitoring urine output, which should be at least 30 mL/hr, and hematocrit levels is essential to assess the client's hydration status and overall hemodynamic stability.

Choice A rationale

While social support is important for mental health, encouraging social events is not the highest priority during the initial phase of bulimia nervosa treatment. Social situations can sometimes be a source of stress or provide opportunities for secretive binge eating behaviors. The primary focus must be on the physiological and psychological triggers of the disorder rather than social reintegration, which usually follows once the client has developed more stable and healthy coping mechanisms for their emotions.

Choice B rationale

Assessing for impulsive eating is a relevant part of the diagnostic process, but it is a descriptive assessment rather than a targeted intervention. While understanding the patterns of consumption is helpful, the priority remains the identification of why the behavior is occurring. Simply noting that eating is impulsive does not provide the client with the tools needed to interrupt the cycle of binging and purging, which is the ultimate goal of the therapeutic nursing intervention in this setting.

Choice C rationale

Instituting a restricted calorie diet is contraindicated and dangerous for a client with bulimia nervosa. Caloric restriction often serves as a primary trigger for the binge purge cycle, as physiological hunger and feelings of deprivation lead to a loss of control and subsequent overeating. The goal of nutritional therapy in bulimia is to establish a normalized, regular pattern of eating without restriction to stabilize blood sugar levels and reduce the biological drive to binge on large quantities.

Choice D rationale

Identifying triggers is the highest priority because bulimia nervosa is often a maladaptive coping mechanism for dealing with emotional distress, low self esteem, or interpersonal conflict. By recognizing the specific situations, feelings, or thoughts that lead to a binge, the client can work with the healthcare team to develop healthier alternative behaviors. Addressing the root cause of the behavior is essential for long term recovery and for breaking the destructive cycle of binging and compensatory purging.