The emergency department nurse can expect to see which assessment cues in the patient with acute pancreatitis? Select all that apply.
Fever.
Gray-blue discoloration of the flank or umbilical area.
Hypertension.
Decreased amylase level.
Nausea and vomiting.
Severe abdominal pain.
Correct Answer : A,B,E,F
Choice A reason: Fever is a common sign of acute pancreatitis and indicates an inflammatory response. Inflammation of the pancreas can trigger the release of cytokines and other inflammatory mediators, leading to an elevated body temperature. This is a common symptom observed in many cases of acute pancreatitis and suggests an ongoing inflammatory process.
Choice B reason: Gray-blue discoloration of the flank or umbilical area, also known as Grey Turner's sign and Cullen's sign respectively, indicates bleeding and severe inflammation within the pancreas. These signs are indicative of retroperitoneal hemorrhage or pancreatic necrosis, which are severe complications of acute pancreatitis. The presence of such discoloration is a significant finding that suggests a more serious form of the condition.
Choice C reason: Hypertension is not typically associated with acute pancreatitis. In fact, patients with acute pancreatitis are more likely to experience hypotension due to fluid shifts, inflammatory responses, and potential hemorrhage. Monitoring blood pressure is important in these patients to manage any potential complications.
Choice D reason: Decreased amylase level is not an expected finding in acute pancreatitis. Typically, acute pancreatitis is associated with elevated levels of pancreatic enzymes such as amylase and lipase due to inflammation and damage to the pancreatic cells, which release these enzymes into the bloodstream.
Choice E reason: Nausea and vomiting are common symptoms in acute pancreatitis. The inflammation of the pancreas and the associated pain can stimulate the vomiting center in the brain and lead to nausea and vomiting. These symptoms are often severe and can significantly affect the patient's comfort and hydration status.
Choice F reason: Severe abdominal pain is one of the hallmark signs of acute pancreatitis. The pain is typically located in the upper abdomen and may radiate to the back. It is often described as constant and severe, and can be exacerbated by eating or lying flat. Effective pain management is a critical aspect of caring for patients with acute pancreatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The statement "I must stop halfway up the stairs to catch my breath" is a significant indicator of left-sided heart failure. Left-sided heart failure leads to pulmonary congestion, resulting in symptoms such as shortness of breath, especially during physical activities. This occurs because the heart is unable to effectively pump blood to the body, causing fluid buildup in the lungs and leading to exertional dyspnea.
Choice B reason: The statement "I am awakened by the need to urinate at night" refers to nocturia, which can be associated with heart failure but is not as specific to left-sided heart failure as exertional dyspnea. Nocturia can occur due to fluid redistribution when lying down, but it is not a definitive sign of left-sided heart failure alone.
Choice C reason: The statement "I have been drinking more water than usual" is not directly related to left-sided heart failure. Increased water intake could be indicative of other conditions such as diabetes or dehydration, but it is not a specific symptom of left-sided heart failure.
Choice D reason: The statement "I have experienced blurred vision on several occasions" is not typically associated with left-sided heart failure. Blurred vision can result from various causes, including visual disturbances, blood pressure changes, or other medical conditions, but it is not a hallmark symptom of left-sided heart failure.
Correct Answer is B
Explanation
Choice A reason: Monitoring intake and output is important in managing cirrhosis and ascites, as it helps track fluid balance and detect early signs of fluid retention. However, this action alone does not directly decrease the presence of ascites. It is more of a monitoring tool than an intervention that reduces fluid accumulation.
Choice B reason: Providing a low-sodium diet is a key intervention to decrease the presence of ascites in patients with cirrhosis. Sodium restriction helps prevent fluid retention by reducing the amount of sodium in the bloodstream, which in turn decreases the osmotic pressure that draws fluid into the abdominal cavity. This dietary modification is fundamental in the management of ascites.
Choice C reason: Increasing oral fluid intake is not an appropriate action for decreasing the presence of ascites in patients with cirrhosis. Excessive fluid intake can exacerbate fluid retention and worsen ascites. Instead, fluid intake may need to be restricted depending on the patient's condition and electrolyte balance.
Choice D reason: Weighing the patient daily is a useful tool for monitoring fluid status and detecting changes in ascites. However, similar to monitoring intake and output, this action does not directly decrease the presence of ascites. It serves as a means to track the effectiveness of other interventions, such as sodium restriction and medication.
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