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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: The electrician who suffered external burn injuries a month ago is stable enough to be concerned with discharge plans. This indicates that his burns have been managed and he is in a phase of recovery where he is preparing for discharge. Although his request is important, it is not an immediate priority compared to more acute conditions.

Choice B reason: The older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body is in a critical condition and needs continuous monitoring, especially with high fluid administration. However, their condition is currently being managed with IV fluids. While this client requires close observation, there is no immediate indication of a life-threatening change that demands immediate intervention compared to the firefighter's situation.

Choice C reason: The adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain is also in need of pain management and ongoing care. However, pain, while significant and requiring treatment, does not take precedence over the potential airway compromise and respiratory distress posed by smoke inhalation and facial burns in the firefighter.

Choice D reason: The firefighter with smoke inhalation and facial burns who has just arrived on the unit must be assessed first due to the immediate risk of airway compromise and respiratory distress. Smoke inhalation can lead to rapid swelling of the airways, making it a critical emergency. Facial burns also increase the risk of airway obstruction. Prompt assessment and intervention are essential to ensure the firefighter's airway remains patent and to provide necessary respiratory support.

A. Deep vein thrombosis. B. Ascites. C. Splenomegaly. D. Esophageal varices. E. Increased platelet levels.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Deep vein thrombosis is a condition where blood clots form in the deep veins, usually in the legs. While it is a serious condition, it is not directly associated with portal hypertension in patients with late-stage cirrhosis. Portal hypertension primarily affects the liver and its associated blood vessels, leading to complications within the portal circulation system rather than systemic venous thrombosis.

Choice B reason: Ascites is the accumulation of fluid in the abdominal cavity, and it is a common complication of portal hypertension in patients with cirrhosis. Increased pressure in the portal vein leads to leakage of fluid into the abdominal cavity, causing distension and discomfort. Ascites can significantly impact the patient's quality of life and requires careful management.

Choice C reason: Splenomegaly, or enlargement of the spleen, is another potential complication of portal hypertension. The increased pressure in the portal vein can cause blood to back up into the spleen, leading to its enlargement. Splenomegaly can result in hypersplenism, where the spleen becomes overactive and destroys blood cells, contributing to anemia, thrombocytopenia, and leukopenia.

Choice D reason: Esophageal varices are dilated blood vessels in the esophagus that develop as a result of portal hypertension. The increased pressure in the portal vein causes blood to divert through collateral vessels, including those in the esophagus. These varices can rupture and cause life-threatening bleeding, making them a critical complication to monitor in patients with cirrhosis.

Choice E reason: Increased platelet levels are not typically seen in patients with portal hypertension. In fact, portal hypertension and cirrhosis often lead to thrombocytopenia, or low platelet levels, due to splenic sequestration and reduced platelet production. Thrombocytopenia is a more common finding in this patient population.

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The emergency department nurse can expect to see which assessment cues in the patient with acute pancreatitis? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse on a burn unit has just received a change-of-shift report about these clients. Which client does the nurse assess first?

Correct Answer is D

Explanation

A patient with late-stage cirrhosis develops portal hypertension. All of the following are potential complications that can develop from this condition. Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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