Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?

Pancreatic pseudocyst.

Electrolyte imbalance.

Internal bleeding.

Pleural effusion.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Pancreatic pseudocyst is a complication of acute pancreatitis, but it is not directly associated with Cullen’s sign. Cullen’s sign indicates periumbilical ecchymosis, which is a sign of internal bleeding.

Choice B rationale

Electrolyte imbalance can occur in acute pancreatitis, but it is not indicated by Cullen’s sign. Cullen’s sign specifically points to internal bleeding.

Choice C rationale

Internal bleeding is the correct answer. Cullen’s sign is a bluish discoloration around the umbilicus, indicating bleeding within the abdomen. This can occur in severe cases of acute pancreatitis due to hemorrhage.

Choice D rationale

Pleural effusion can be a complication of acute pancreatitis, but it is not indicated by Cullen’s sign. Cullen’s sign is specific to internal bleeding.

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Correct Answer is B

Explanation

Choice A rationale

9 percent is the percentage of total body surface area (TBSA) for one arm (front or back) or the head and neck combined. Since the burns are on the front and back of both arms, this percentage is too low.

Choice B rationale

18 percent is the correct percentage of TBSA for burns on the front and back of both arms. Each arm accounts for 9 percent of TBSA, so both arms together account for 18 percent.

Choice C rationale

36 percent is the percentage of TBSA for burns on both legs (front and back) or the entire trunk (anterior and posterior). This percentage is too high for burns on the front and back of both arms.

Choice D rationale

54 percent is the percentage of TBSA for burns on the entire trunk (anterior and posterior) and one leg (front and back). This percentage is too high for burns on the front and back of both arms.

A. Weak pedal pulses. B. Complaints of leg discomfort. C. Toes are warm and demonstrate a brisk capillary refill. D. Drainage at the pin sites.

Correct Answer is A

Explanation

Choice A rationale

Weak pedal pulses indicate vascular compromise, which is a complication of Buck’s traction. This can be caused by pressure on the tissues of the leg.

Choice B rationale

Complaints of leg discomfort are expected due to the traction and do not indicate a complication.

Choice C rationale

Toes that are warm and demonstrate brisk capillary refill are normal findings and do not indicate a complication.

Choice D rationale

Drainage at the pin sites is more relevant to skeletal traction, not Buck’s traction.

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Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has burns on the front and back of both arms. Using the rule of nines, the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?

Correct Answer is B

Explanation

The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

Correct Answer is A

Explanation

A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?

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