The nurse is assessing a patient being admitted with fatigue and shortness of breath as well as abdominal tenderness who presents with jaundice and an enlarged liver. What does the nurse suspect that the patient has?

Rationale:

A. Agitation is incorrect because it is a hallmark of hyperactive delirium. Patients with hyperactive delirium may be visibly restless, aggressive, or emotionally labile, often exhibiting behaviors such as shouting, pacing, or striking out. Agitation is not characteristic of hypoactive delirium.

B. Restlessness is incorrect for hypoactive delirium; it is typically seen in hyperactive delirium. Restlessness includes constant movement, fidgeting, or an inability to stay calm, which contrasts with the lethargy seen in hypoactive states.

C. Hitting is incorrect because combative or aggressive behaviors occur in hyperactive delirium, not hypoactive delirium. Patients in the hypoactive state are more passive and withdrawn rather than outwardly aggressive.

D. Withdrawal is correct because hypoactive delirium is characterized by reduced psychomotor activity, lethargy, decreased responsiveness to the environment, and social withdrawal. Patients may appear drowsy, quiet, and unengaged, often seeming “sleepy” or “apathetic.” They may show minimal interaction with staff or family, have slowed speech, and be less likely to communicate discomfort or needs.

Rationale:
A. It is caused by dilation of the biliary system is incorrect because, although gallstones and biliary obstruction can trigger acute pancreatitis, this option explains a possible cause of pancreatitis rather than why pain control is a nursing priority. It does not address the physiologic consequences of uncontrolled pain.

B. It decreases the patient’s metabolism is incorrect because pain typically increases metabolic demand and stress hormone release rather than decreasing metabolism. Uncontrolled pain leads to increased oxygen consumption and energy expenditure.

C. It increases pancreatic secretions is correct because pain and stress stimulate the sympathetic nervous system, which can increase pancreatic enzyme secretion. Increased enzyme release worsens pancreatic inflammation and autodigestion. Effective pain control helps reduce pancreatic stimulation, limits further tissue damage, and promotes healing.

D. It is caused by decreased distention of the pancreatic capsule is incorrect because pain in acute pancreatitis is associated with inflammation, edema, and increased distention of the pancreatic capsule, not decreased distention.