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A nurse in a medical-surgical unit is caring for a client.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes
Day 1, 0330:
Client presents for evaluation of severe pain in upper abdomen that radiates into their back. States pain began approximately 12 hr ago and is worse when they are supine or after they eat. Rates pain as 7 on a scale of 0 to 10. Sclera noted to be yellow. Heart rate regular, lungs clear to auscultation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday. Reports no recent illnesses takes no prescribed medications. Client is alert and oriented x4.

Client presents for evaluation of severe pain in upper abdomen that radiates into their back.

States pain began approximately 12 hr ago and is worse when they are supine or after they eat.

Rates pain as 7 on a scale of 0 to 10. Sclera noted to be yellow.

Heart rate regular, lungs clear to auscultation.

Abdomen firm, bowel sounds hypoactive.

Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday.

Reports no recent illnesses takes no prescribed medications.

Client is alert and oriented x4.

Answer and Explanation

The Correct Answer is ["A","B","C","E","F"]

Rationale for Correct Choices:

Pain radiating to the back, worsens after eating or lying down: This is characteristic of acute pancreatitis, where inflammation irritates surrounding tissues and worsens in the supine position due to gravitational pressure. Postprandial worsening suggests pancreatic enzyme stimulation.
Scleral icterus (yellow sclera and palate): Jaundice suggests biliary obstruction or liver involvement, possibly due to gallstone pancreatitis or alcoholic liver disease. This also aligns with the elevated bilirubin levels and warrants further hepatic and biliary assessment.
Abdomen distended, rigid, and tender with guarding: These are signs of peritonitis or severe intra-abdominal inflammation, requiring urgent evaluation. Guarding and rigidity indicate localized or diffuse peritoneal irritation from pancreatic enzymes.
Hypoactive bowel sounds: Reduced bowel activity is often seen in pancreatitis due to paralytic ileus caused by inflammation and stress response. Monitoring for progression to ileus or obstruction is necessary.
Client guards abdomen and grimaces during palpation: Guarding and pain upon palpation are signs of significant intra-abdominal inflammation. It may reflect worsening pancreatitis or complications such as necrosis or peritonitis.

Rationale for Incorrect Choices:

Heart rate regular, lungs clear to auscultation: These are normal findings and do not require follow-up.
Client is alert and oriented x4: Indicates normal neurologic status. No immediate concern here.
Reports no recent illnesses, takes no prescribed medications: This helps rule out medication-induced pancreatitis and doesn't indicate a need for follow-up.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

Intravenous antibiotic: The client shows multiple signs of endometritis: uterine tenderness, foul-smelling lochia, fever, tachycardia, and elevated WBC count. IV antibiotics are the first-line treatment for postpartum uterine infections, particularly after cesarean delivery with risk factors like prolonged rupture of membranes.
Increase in daily fluid intake: Clients with infection and fever require increased hydration to support perfusion, manage elevated metabolic demands, and help clear the infection. Fever and poor bowel motility may also contribute to mild dehydration, making fluid support essential.

Rationale for Incorrect Choices:

Intrauterine tamponade balloon: This is used to control postpartum hemorrhage due to uterine atony or trauma. Although the fundus was boggy, it firmed with massage, and there is no indication of active or excessive bleeding, making tamponade unnecessary.
Kleihauer-Betke test: This test detects fetal blood in the maternal circulation and is used after trauma or suspected fetal-maternal hemorrhage, especially in Rh-negative mothers. It is not relevant to this postpartum infection scenario.
Tocolytic medication: Tocolytics are used during pregnancy to suppress preterm labor by relaxing the uterus. In the postpartum period, they are not indicated and would be contraindicated in the presence of infection, as they can reduce uterine tone and worsen involution.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

Rationale for correct choices:

Opioid intoxication: The client's decreased respiratory rate, drowsiness, pinpoint pupils, and positive response to naloxone are all indicative of opioid intoxication. These features, along with the presence of a needle in the antecubital space, strongly support recent opioid use and CNS depression.
Pupil characteristics: Miotic pupils, or pinpoint pupils, are a classic physical sign of opioid intoxication. They occur due to opioid stimulation of the parasympathetic nervous system, and in a sedated client with a history of injection drug use, they confirm the likelihood of opioid overdose.

Rationale for incorrect choices:

Alcohol intoxication: Alcohol intoxication usually presents with disinhibition, unsteady gait, slurred speech, and potentially aggressive or inappropriate behavior. The client’s severe sedation, low respiratory rate, and constricted pupils are not typical features of alcohol intoxication, especially with only one beer reported.
Alcohol withdrawal: Alcohol withdrawal manifests with symptoms like tremors, agitation, hallucinations, seizures, and autonomic instability (tachycardia, hypertension). This client is sedated with bradypnea and hypotension, which are incompatible with alcohol withdrawal and more suggestive of CNS depression.
Opioid withdrawal: Opioid withdrawal is marked by agitation, anxiety, mydriasis, vomiting, diarrhea, and piloerection. In contrast, this client is drowsy, has decreased bowel sounds, and constricted pupils, pointing toward active opioid intoxication rather than withdrawal.
Amount of alcohol consumed: The report from EMS indicates the client consumed only one beer, which is insufficient to explain the severity of the symptoms. Minimal alcohol intake also makes both intoxication and withdrawal from alcohol highly unlikely as the primary issue.
Current temperature: The client’s current temperature of 37.2°C (99°F) is within normal limits and does not support any particular diagnosis. It neither confirms nor excludes opioid or alcohol intoxication or withdrawal and is not a defining clinical sign in this context.
Breath sounds: Breath sounds are equal and clear, offering no abnormal findings to support or contradict a diagnosis. While important for general assessment, they are not specific indicators for opioid intoxication or withdrawal and thus are less relevant than pupil changes.

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Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is caring for a client. Exhibits The nurse should anticipate a provider's prescription for a(n) dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

A nurse is caring for a client in the emergency department. Exhibits The nurse reviews the medical record. Complete the following sentence by using the lists of options The client likely experienced dropdown as evidenced by dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

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