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 A

Explanation

Choice A rationale

The weights from the traction device should only be removed if the client develops a life- threatening situation. This is to ensure the client’s immediate safety and address the critical condition.

Choice B rationale

The client should not have the weights removed for repositioning in the bed. Proper techniques should be used to reposition the client without removing the weights to maintain the effectiveness of the traction.

Choice C rationale

Complaints of pain should be addressed by assessing the cause and providing appropriate pain management, but the weights should not be removed as it can compromise the traction.

Choice D rationale

The weights should not be removed for an x-ray. The traction can be maintained during imaging procedures to ensure continuous treatment.

A. 9 percent. B. 18 percent. C. 36 percent. D. 54 percent.

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.

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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 is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?

Correct Answer is A

Explanation

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

A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

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?

A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?

A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?