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 ["A","C","D"]
Explanation
Choice A reason: Slowed movement when rising from a chair is a common symptom of Parkinson's disease, known as bradykinesia.
Choice B reason: Chronic diarrhea is not typically associated with Parkinson's disease.
Choice C reason: Difficulty swallowing, or dysphagia, is a common issue in Parkinson's disease due to impaired muscle control.
Choice D reason: A shuffling gait is characteristic of Parkinson's disease, often referred to as "festinating gait."
Choice E reason: Lower extremity edema is not a typical symptom of Parkinson's disease and may indicate other health issues.
Correct Answer is B
Explanation
Choice A reason: While individuals with rheumatoid arthritis may have an increased risk of infection due to the disease itself or the use of immunosuppressive medications, it does not pose as high a risk as intravenous lines for sepsis.
Choice B reason: A peripherally inserted central catheter (PICC) line, especially when used for total parenteral nutrition (TPN), presents a significant risk for infection due to the direct access to the bloodstream, making this client at the highest risk for sepsis.
Choice C reason: Asthma and bronchitis can lead to respiratory infections, but these conditions do not typically result in sepsis unless the infection becomes severe and systemic.
Choice D reason: Renal calculi (kidney stones) can cause infections; however, they are less likely to lead to sepsis compared to a central line.
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