The nurse is monitoring a patient admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in two hours. The patient begins to vomit. On assessment, the nurse notes that the abdomen is distended, and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

Administer the prescribed pain medication

Reposition the patient and apply a heating pad on the warm setting to the patient’s abdomen

Notify the primary health care provider (PHCP)

Call and ask the operating room team to perform surgery as soon as possible

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering pain medication may mask symptoms of appendicitis progression, such as perforation, which vomiting and distension suggest. Pain relief does not address the underlying issue or potential complications like peritonitis. Notifying the provider is prioritized to reassess the patient’s worsening condition, which may require urgent surgical intervention.

Choice B reason: Applying a heating pad to the abdomen is contraindicated in appendicitis, as heat can increase inflammation, potentially causing appendix rupture. Repositioning does not address vomiting or distension. These symptoms indicate possible complications, requiring medical evaluation, not comfort measures that could worsen the patient’s condition.

Choice C reason: Notifying the primary health care provider is critical, as vomiting, abdominal distension, and diminished bowel sounds suggest appendicitis progression or complications like perforation or peritonitis. These findings warrant urgent reassessment, possibly advancing surgery or ordering imaging, to prevent life-threatening complications like sepsis or abscess formation in this acute condition.

Choice D reason: Calling the operating room to expedite surgery bypasses the primary provider’s assessment, which is needed to confirm the patient’s status. Vomiting and distension may indicate perforation, requiring imaging or immediate evaluation. Direct communication with the provider ensures appropriate decision-making, as surgery timing depends on clinical reassessment, not nurse-initiated scheduling.

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Correct Answer is D

Explanation

Choice A reason: Eye twitching is unrelated to Cullen’s sign or pancreatitis. It may occur in electrolyte imbalances like hypocalcemia, but pancreatitis typically causes hypercalcemia due to fat necrosis. Cullen’s sign is a specific dermatological finding linked to intra-abdominal bleeding, not neurological or muscular symptoms like twitching.

Choice B reason: Pain on palpation of the right upper quadrant (RUQ) is associated with conditions like cholecystitis, not Cullen’s sign. Pancreatitis causes epigastric or left upper quadrant pain. Cullen’s sign indicates retroperitoneal hemorrhage, manifesting as periumbilical bruising, not RUQ tenderness, which is unrelated to this physical finding.

Choice C reason: Petechiae scattered on the back are not indicative of Cullen’s sign. Petechiae suggest thrombocytopenia or coagulopathy, not specific to pancreatitis. Cullen’s sign is localized bruising around the umbilicus due to intraperitoneal or retroperitoneal bleeding, distinguishing it from diffuse petechiae, which have a different etiology and distribution.

Choice D reason: Cullen’s sign is a bruised, blue-gray appearance around the umbilicus, indicating retroperitoneal or intraperitoneal hemorrhage in severe pancreatitis. Blood tracks along fascial planes to the periumbilical area, causing discoloration. This sign reflects significant pancreatic inflammation or necrosis, making it a critical finding in assessing pancreatitis severity.

A. Heart failure B. Thirst C. Dysrhythmias D. Vasoconstriction

Correct Answer is D

Explanation

Choice A reason: Heart failure is not directly caused by vasopressin in CAD patients. Vasopressin increases water reabsorption in the kidneys, potentially increasing blood volume, which could strain the heart in severe cases. However, its primary concern in CAD is vasoconstriction, not heart failure, as it does not directly impair cardiac contractility or cause decompensation.

Choice B reason: Thirst is a symptom of diabetes insipidus due to dehydration from excessive urine output, not a side effect of vasopressin. Vasopressin replaces ADH, reducing urine output and thirst. It does not induce thirst in CAD patients, making this choice irrelevant to the cardiovascular risks associated with vasopressin administration.

Choice C reason: Dysrhythmias are not a primary concern with vasopressin in CAD. Vasopressin causes vasoconstriction, increasing vascular resistance and myocardial oxygen demand, which can lead to ischemia in CAD patients. While ischemia may rarely trigger dysrhythmias, the direct effect of vasopressin is vasoconstriction, not arrhythmias, making this choice less accurate.

Choice D reason: Vasoconstriction is a significant risk of vasopressin in CAD patients. Vasopressin, an ADH analog, causes systemic vasoconstriction, increasing blood pressure and myocardial oxygen demand. In CAD, this can exacerbate ischemia by reducing coronary blood flow, potentially leading to angina or infarction, making caution necessary in these patients.

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Naxlex Comprehensive Predictor Exams

A patient with pancreatitis has a positive Cullen’s sign. What does the nurse expect to see upon physical examination that is associated with a positive Cullen’s sign?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

The nurse reviews the chart and signs the order: “Paracentesis now, to rule out spontaneous bacterial peritonitis.” What will the nurse include in the plan of care? (Select all that apply)

The nurse is caring for a patient with gastroenteritis. He not only has diarrhea and dehydration but also complains of feeling very warm. What systemic response may the patient experience with this inflammatory infection?

A nurse admits a patient to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

The nurse analyzes the laboratory results of a patient with hemophilia. The nurse understands that which result will most likely be abnormal in this patient?

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A nurse is caring for a patient who has secondary obesity. Which condition is the most likely to result in secondary obesity?

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