A client with acute pancreatitis has the following assessment: abdominal pain 7/10, nausea and vomiting for 2 days, vital signs: BP 108/70 mmHg, temperature 99.8°F, pulse 98 bpm, respiratory rate 22 breaths/min, inelastic skin turgor, and concentrated urine. Which nursing diagnosis should the nurse select as a priority?
Impaired elimination.
Fluid imbalance.
Fever.
Nausea.
The Correct Answer is B
Choice A reason: Impaired elimination may be a concern with pancreatitis due to potential complications affecting the gastrointestinal tract, but it is not the immediate priority.
Choice B reason: Fluid imbalance is the most critical issue in acute pancreatitis, as evidenced by inelastic skin turgor and concentrated urine, indicating dehydration, which can exacerbate the condition and lead to hypovolemic shock.
Choice C reason: Fever may be present due to inflammation or infection, but the temperature provided is not indicative of a significant fever and is not the priority over fluid imbalance.
Choice D reason: Nausea is a symptom of acute pancreatitis and while it needs to be managed, it is not the priority over fluid imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The ABG values provided are within normal limits and do not indicate a complication of sepsis.
Choice B reason: A temperature of 100.8°F suggests an infection but is not specific enough to indicate a complication of sepsis.
Choice C reason: A platelet count of 99,000/mm3 is below the normal range and can indicate a complication of sepsis known as disseminated intravascular coagulation (DIC), which is a serious condition that can lead to severe bleeding or blood clots.
Choice D reason: A urine culture positive for gram-negative bacteria indicates an infection, which could be the source of sepsis, but it does not specifically indicate a complication of sepsis.
Correct Answer is A
Explanation
Choice A reason: In sepsis, inflammatory mediators cause vasodilation and increased capillary permeability, leading to fluid leaking out of the vascular space, resulting in hypotension.
Choice B reason: Platelet aggregation and thrombus formation can occur in sepsis but are more related to disseminated intravascular coagulation (DIC) rather than directly causing hypotension.
Choice C reason: Decreased blood glucose and oliguria can be consequences of sepsis but are not the primary pathophysiological processes responsible for hypotension.
Choice D reason: Hypoxemia and anaerobic metabolism may result from the effects of sepsis on the body, including hypotension, but they are not the direct cause of hypotension.
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