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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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. Expect to have a rapid pulse rate for the first few weeks: A newly implanted ICD does not cause a rapid heart rate. In fact, it monitors for dangerous rhythms and delivers a shock if one is detected. A rapid pulse could signal a complication and should be reported immediately.

B. Return in two weeks for a follow-up MRI: MRIs are generally contraindicated unless the ICD is MRI-compatible, which is not always the case. Strong magnetic fields can interfere with the device, so alternative imaging is typically used unless cleared by a cardiologist.

C. Resume tub baths and swimming after 24 hr: Clients should avoid submerging the incision site in water until it is fully healed, typically after several weeks. Early immersion increases the risk of infection at the surgical site.

D. Wear loose-fitting clothing: Loose clothing prevents irritation and pressure on the incision site during the healing process. It also helps reduce discomfort and lowers the risk of disturbing the ICD leads or dressing.

A. Temperature B. Vomiting C. Abdominal findings D. Stool E. Pain rating

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"A,C"},"E":{"answers":"B,C"}}

Explanation

Rationale:

Temperature: The child’s temperature is 37.4°C (99.3°F), which is mildly elevated. Crohn’s disease typically causes intermittent fever during flare-ups. Appendicitis often presents with a higher fever in later stages. Intussusception can cause low-grade fever due to bowel inflammation, making it the most consistent with this finding.
Vomiting: Vomiting is uncommon in Crohn’s disease unless there’s obstruction or severe disease. In appendicitis, vomiting usually follows the onset of pain and is related to peritoneal irritation. Intussusception often involves vomiting early due to intermittent bowel obstruction, making it consistent with this client’s symptoms.
Abdominal findings: Crohn’s disease rarely produces a palpable abdominal mass or sudden distension. Appendicitis can cause right-sided tenderness and decreased bowel sounds but does not typically involve a mass. Intussusception often presents with a distended abdomen, hypoactive bowel sounds, and a sausage-shaped mass in the right upper quadrant, as described.
Stool: Crohn’s disease can lead to bloody, mucus-filled stools due to ulceration in the intestinal lining. Appendicitis does not typically alter stool characteristics unless perforation occurs. Intussusception is well known for producing “currant jelly” stools, composed of blood and mucus, aligning with this child’s bowel movement description.
Pain rating: A FLACC score of 5 indicates moderate pain. Crohn’s pain tends to be chronic and crampy rather than episodic. Appendicitis pain worsens over time and becomes localized, typically in the right lower quadrant. Intussusception causes intermittent, severe abdominal pain with sudden relief, matching the child’s pain episodes and behavior.

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Naxlex Comprehensive Predictor Exams

A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include?

Correct Answer is D

Explanation

Exhibits For each potential assessment finding, click to specify if the finding is consistent with Crohn’s disease, appendicitis or intussusception. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"A,C"},"E":{"answers":"B,C"}}

Explanation

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