A client is brought to the hospital because of severe abdominal pain, nausea, and vomiting. The client reports increased pain in the abdomen and in the epigastric region radiating to the back when lying supine. Upon physical assessment, the nurse finds that the client has fever and hypotension.
What should the nurse infer from these findings?
The client has chronic pancreatitis.
The client has cholecystitis.
The client has cholelithiasis.
The client has acute pancreatitis.
The Correct Answer is D
Choice A rationale: Symptoms and findings described align more with an acute, severe condition rather than a chronic one.
Choice B rationale: While cholecystitis can present with similar symptoms, the radiation of pain to the back is more indicative of a different condition.
Choice C rationale: Cholelithiasis (gallstones) might cause abdominal pain but typically doesn’t lead to fever and hypotension.
Choice D rationale: Symptoms including severe abdominal pain, radiation to the back, fever, and hypotension suggest acute pancreatitis, a potentially serious condition requiring urgent medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Kayexalate is not primarily used for phosphate reduction.
Choice B rationale: Kayexalate can have sorbitol in its formulation, which might cause diarrhea rather than constipation.
Choice C rationale: Kayexalate works as a cation-exchange resin that promotes potassium excretion in the bowels.
Choice D rationale: Kayexalate does not add potassium; it exchanges sodium for potassium in the bowels.
Correct Answer is D
Explanation
Choice A rationale: Activates the rapid response team (RRT) - Status epilepticus is a medical emergency requiring immediate intervention. Activating the rapid response team would ensure a prompt response to the situation.
Choice B rationale: Loosens any restrictive clothing - It is important for patient safety and comfort.
Choice C rationale: Places the client in a lateral position - This is a recommended positioning to prevent aspiration during a seizure.
Choice D rationale: Prepares to administer intravenous valproate acid - Valproic acid is not the first drug during epilepsy hence this action would necessitate immediate intervention.
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