A client is being cared for in the emergency department (ED) with acute abdominal pain and a provisional diagnosis of pancreatitis. The nurse assesses the client and obtains the results from laboratory studies. Which information is most valuable in reporting the client’s status to the healthcare provider (HCP)?
Reports of chronic constipation and serum gastrin levels
Presence of bowel sounds and degree of abdominal pain
Severity of nausea and vomiting and serum amylase results
Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts
The Correct Answer is C
Choice A reason: Chronic constipation and gastrin levels are irrelevant to pancreatitis. Gastrin relates to gastric acid production, not pancreatic inflammation. Pancreatitis is confirmed by amylase/lipase elevation, and constipation does not reflect its severity, making this information less valuable for reporting.
Choice B reason: Bowel sounds and abdominal pain degree provide general data but are non-specific. Pancreatitis requires amylase/lipase levels for diagnosis, and nausea/vomiting severity better indicates clinical status, making this information secondary to laboratory confirmation and symptom severity.
Choice C reason: Severity of nausea and vomiting and serum amylase results are critical, as elevated amylase confirms pancreatitis, and nausea/vomiting severity reflects disease impact. These directly inform the provider about pancreatic inflammation and clinical status, making this the most valuable information to report.
Choice D reason: H. pylori antibodies and urine output are unrelated to pancreatitis. H. pylori causes gastritis, and urine output monitors hydration, but amylase and nausea/vomiting directly address pancreatitis’s diagnosis and severity, making this information less relevant for immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Offering mouthwash may irritate painful candidiasis ulcers in AIDS, as alcohol-based solutions exacerbate discomfort. While cleansing is important, a soft-bristled toothbrush is gentler, effectively cleaning without worsening mucosal damage, making this choice less appropriate for oral care.
Choice B reason: Providing a soft-bristled toothbrush is correct, as it gently cleans the mouth without irritating painful candidiasis ulcers in AIDS. Soft bristles minimize trauma to inflamed mucosa, promoting hygiene and comfort, making this the best instruction for safe and effective oral care by the UAP.
Choice C reason: Leaving oral care to the nurse is unnecessary, as UAPs can perform oral hygiene with proper instruction. Delegating soft-bristled toothbrush use ensures safe care for candidiasis, and reserving this task for nurses limits efficiency without clinical justification, making this choice incorrect.
Choice D reason: Wearing sterile gloves is excessive, as candidiasis is opportunistic, not requiring sterile technique. Standard precautions with clean gloves suffice for oral care in AIDS, as sterile gloves are reserved for invasive procedures, making this instruction inappropriate for routine mucosal cleansing.
Correct Answer is B
Explanation
Choice A reason: Clay-colored stool indicates bile duct obstruction, not directly related to esophageal varices in cirrhosis. Varices are dilated veins prone to rupture, and while liver dysfunction affects bile, hematemesis is a more immediate, life-threatening complication, making this choice less critical.
Choice B reason: Hematemesis is critical to monitor, as esophageal varices in cirrhosis are fragile, dilated veins that can rupture, causing massive upper gastrointestinal bleeding. This leads to life-threatening hemorrhage, requiring urgent intervention, making it the priority due to its high mortality risk in portal hypertension.
Choice C reason: Anorexia is common in cirrhosis due to metabolic changes but is not specific to varices. While it affects nutrition, it is less urgent than hematemesis, which indicates variceal bleeding, a medical emergency, making this choice secondary to bleeding risk.
Choice D reason: Brown, foamy urine suggests renal issues, like proteinuria, not directly linked to esophageal varices. Variceal bleeding is a more immediate threat in cirrhosis, as urine changes are unrelated to portal hypertension’s acute complications, making this choice less critical.
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