A nurse is collecting data from a client who has acute pancreatitis. Which of the following findings should the nurse expect?
Pain relieved by the prone position
Decreased WBC count
Hyperactive bowel sounds
Epigastric pain
The Correct Answer is D
A. Pain relieved by the prone position: Pain from acute pancreatitis is typically not relieved by lying prone. Clients often find some relief by sitting up, leaning forward, or assuming a fetal position, as these positions reduce pressure on the inflamed pancreas.
B. Decreased WBC count: Acute pancreatitis usually triggers an inflammatory response, leading to an elevated white blood cell (WBC) count, not a decreased one. Leukocytosis is a common laboratory finding associated with the body's reaction to inflammation and possible infection.
C. Hyperactive bowel sounds: In acute pancreatitis, bowel sounds are often decreased or absent due to paralytic ileus. Hyperactive bowel sounds would be more suggestive of other gastrointestinal disturbances such as diarrhea or early intestinal obstruction.
D. Epigastric pain: Severe, persistent epigastric pain that may radiate to the back is the hallmark symptom of acute pancreatitis. This pain is typically sudden in onset and worsens after eating or drinking, especially fatty foods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pain radiating down the left arm: Pain radiating to the left arm is more commonly associated with myocardial infarction (heart attack), not a transient ischemic attack (TIA). It indicates cardiac ischemia rather than a temporary disruption in cerebral blood flow.
B. Seizure activity: Seizures are not characteristic of transient ischemic attacks. While seizures can occur after significant brain injury such as a stroke, TIAs typically present with focal neurological deficits that resolve quickly without leading to seizure activity.
C. Sudden loss of vision in one eye: A sudden, temporary loss of vision in one eye (amaurosis fugax) is a classic sign of a TIA. It reflects temporary ischemia in the retinal or cerebral blood vessels and warrants immediate medical evaluation to prevent a full-blown stroke.
D. Epigastric pain: Epigastric pain is usually related to gastrointestinal issues such as gastritis, ulcers, or gallbladder disease. It is not indicative of a transient ischemic attack and would not typically be prioritized in assessing for neurological compromise.
Correct Answer is C
Explanation
A. Apply lotion between toes: Lotion should not be applied between the toes because the moisture can promote fungal infections. Instead, lotion can be applied to the tops and bottoms of the feet to prevent dryness and cracking.
B. Use a heating pad to warm feet: Clients with diabetes often have decreased sensation in their feet and using heating pads can cause burns without them realizing it. Safer methods, like wearing warm socks, should be used to keep feet warm.
C. Apply cotton socks to feet daily: Wearing clean, dry cotton socks daily helps protect the feet, maintain warmth, and absorb moisture, reducing the risk of fungal infections and skin breakdown, which are common concerns for clients with diabetes.
D. Inspect appearance of feet weekly: Clients with diabetes should inspect their feet daily, not weekly. Daily inspection helps catch cuts, blisters, or signs of infection early to prevent serious complications such as ulcers or amputations.
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