The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min, Respirations = 28 breaths/min, Blood pressure = 92/50. What complication of acute pancreatitis would the nurse suspect?

Electrolyte imbalance

Pleural effusion

Internal bleeding

Pancreatic pseudocyst

Answer and Explanation

The Correct Answer is C

Acute pancreatitis can lead to necrotizing changes that erode major abdominal blood vessels, resulting in retroperitoneal hemorrhage. This leads to a rapid loss of intravascular volume, manifesting as hypovolemic shock. Early recognition of shifting hemodynamic parameters is critical, as hemorrhagic pancreatitis has a high mortality rate due to the combination of blood loss and systemic inflammatory response syndrome.

Rationale:

A. Electrolyte imbalances, specifically hypocalcemia, are common in pancreatitis due to fat necrosis and soap formation. However, they do not typically manifest with this specific triad of hypotension, tachycardia, and tachypnea. These vital signs indicate a primary circulatory failure rather than a purely chemical or mineral imbalance in the blood.

B. Pleural effusion can occur in pancreatitis as inflammatory exudate travels through the diaphragm, causing respiratory distress and tachypnea. While the patient's respirations are elevated (28/min), pleural effusion alone does not explain the significant hypotension (92/50). The combination of low blood pressure and high heart rate suggests a volume-related vascular emergency.

C. The nurse should suspect internal bleeding (hemorrhagic pancreatitis). The combination of tachycardia (116 bpm) and hypotension (92/50) are classic indicators of hypovolemic shock. Pancreatic enzymes can digest the walls of adjacent blood vessels, leading to massive retroperitoneal hemorrhage. This is a critical complication requiring aggressive fluid resuscitation and potentially surgical or radiological intervention.

D. A pancreatic pseudocyst is a localized collection of fluid, enzymes, and debris that forms over weeks. While it can cause pain or become infected (abscess), it does not cause an acute hemodynamic collapse. The vital signs provided in the question indicate an acute, life-threatening vascular event rather than a subacute or chronic fluid collection complication.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Acute gastritisinvolves sudden inflammation of the gastric mucosa, often triggered by chemical irritants or medications. Prostaglandinsare essential for maintaining the protective mucus barrier of the stomach. Agents that inhibit these protective lipids, particularly NSAIDs, leave the epithelium vulnerable to auto-digestion by hydrochloric acid, leading to erosions, hemorrhage, and severe epigastric pain.

Rationale:

A.Smoking cigarettes is a known risk factor that impairs gastric mucosal healing and increases acid secretion. Nicotine reduces the secretion of pancreatic bicarbonate and slows the healing process of gastric erosions. While this habit is harmful, the client's statement about NSAID use represents a more direct and acute physiological threat to the integrity of the gastric lining in this specific diagnosis.

B.The statement about taking ibuprofen indicates a need for further teaching because NSAIDs are a primary cause of acute gastritis. Ibuprofen inhibits the cyclooxygenase-1 enzyme, which is responsible for synthesizing protective prostaglandins in the stomach. Even occasional use can disrupt the mucosal barrier, leading to further inflammation, ulceration, or life-threatening gastric hemorrhage in a patient already diagnosed with gastritis.

C.Decreasing caffeinated drinks is an appropriate action for a patient with acute gastritis. Caffeine stimulates the parietal cells to increase the production of gastric acid, which can worsen inflammation and pain. The client’s understanding of this dietary restriction shows that the previous teaching regarding gastric irritants was successful and does not require further correction by the nurse.

D.Cutting down on alcohol is a correct self-care measure as ethanol is a direct mucosal toxin. Alcohol causes acute damage to the gastric epithelium and increases the risk of erosive gastritis and bleeding. The client’s recognition that nightly martinis are problematic demonstrates an accurate understanding of the lifestyle changes needed to allow the gastric mucosa to recover and heal.

A. Decreased serum iron B. Decreased white blood cell count C. Increased platelet count D. Decreased hemoglobin E. Increased hematocrit F. Decreased red blood cell count

Correct Answer is ["A","D","F"]

Explanation

Iron deficiency anemiais a microcytic, hypochromic anemia resulting from inadequate elemental ironto support erythropoiesis. Iron is a structural component of the hememolecule within hemoglobin, which is essential for oxygen transport. Specific laboratory markers reflect the depletion of iron stores and subsequent reduction in the functional oxygen-carrying capacityof circulating erythrocytes.

Rationale:

A.Decreased serum iron is a hallmark finding in this condition. As total body iron stores are exhausted, the amount of iron circulating in the blood drops significantly. This lack of available iron prevents the bone marrow from synthesizing sufficient hemoglobin for new red blood cells, directly leading to the clinical manifestations of anemia.

B.Decreased white blood cell count is not a characteristic finding of iron deficiency anemia. Leukocytes are part of the immune system and their production is generally independent of iron metabolism. A low white blood cell count would more likely indicate a bone marrow suppression issue or an acute viral infection rather than simple iron deficiency.

C.Increased platelet count, or reactive thrombocytosis, can sometimes occur in iron deficiency, but it is not the primary expected diagnostic finding for the anemia itself. Platelets are involved in hemostasis rather than oxygen transport. While seen in some clinical cases, it does not confirm the diagnosis of iron deficiency anemia like red cell indices do.

D.Decreased hemoglobin is a primary diagnostic criterion for iron deficiency anemia. Hemoglobin is the protein responsible for binding oxygen; without enough iron, the body cannot produce adequate amounts of this protein. This reduction results in the classic symptoms of fatigue, pallor, and dyspnea due to decreased systemic oxygen delivery to tissues.

E.Increased hematocrit is the opposite of what is expected in anemia. Hematocrit measures the percentage of blood volume made up of red blood cells. In iron deficiency anemia, both the size and the total number of red blood cells typically decrease, which leads to a significantly lower hematocrit percentage rather than an increase.

F.Decreased red blood cell count occurs as the iron deficiency becomes chronic and severe. While the body initially produces smaller cells (microcytosis), eventually the total quantity of red blood cells produced by the bone marrow diminishes. This reduction in the total erythroid mass contributes to the overall decrease in the patient's hematocrit and hemoglobin levels.

View Question and Answer

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

The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min, Respirations = 28 breaths/min, Blood pressure = 92/50. What complication of acute pancreatitis would the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a client who has been diagnosed with acute gastritis. What statement by the client indicates a need for further teaching?

Correct Answer is B

Explanation

The nurse is assessing a client experiencing iron deficiency anemia. Which laboratory findings will the nurse expect for this client? Select all that apply

Correct Answer is ["A","D","F"]

Explanation

A client with a history of chronic liver disease presents to the clinic with abdominal distension and discomfort. Physical examination reveals moderate ascites. The patient is prescribed a low-sodium diet and diuretics. Which nursing intervention is a priority for this patient?

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report?

A client is admitted to the hospital with right lower quadrant abdominal pain, nausea, and vomiting. What assessment would the nurse monitor to identify a potentially life-threatening complication based on the client’s condition?

A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. What data requires immediate intervention?

The nurse is caring for a client with hepatitis C. The client’s brother states, “I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond?

The nurse is caring for a client who reports stomach pain and heartburn. Which assessment finding is most significant suggesting the client’s ulcer is duodenal and not gastric?

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client’s understanding. Which statement by the client indicates the correct understanding of the teaching?

A nurse assesses a client who has a history of polycystic kidney disease (PKD). Which assessment findings would the nurse expect? (Select all that apply)