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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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Correct Answer is C

Explanation

Rationale:

A. Rotate staff members caring for the client: Clients with paranoid personality disorder often struggle with trust and may become more suspicious if care is inconsistent. Assigning consistent staff helps build therapeutic rapport and minimizes perceived threats.

B. Mix the medication with the client’s food items: Covertly administering medications violates the client’s autonomy and can worsen paranoia if discovered. Open, honest communication is essential when working with clients who have paranoid thoughts.

C. Speak in a neutral tone when addressing the client: A neutral, calm, and nonjudgmental tone reduces perceived hostility or manipulation. It supports the development of trust and helps avoid triggering defensive or suspicious behaviors.

D. Limit the client’s opportunities to socialize with others: Social interaction should not be restricted unless it poses a safety risk. Encouraging appropriate socialization may help reduce isolation and reinforce reality, even if the client has difficulty with interpersonal relationships.

A. The client reports a pain level of 6 on a scale from 0 to 10 B. The client refuses to look at the colostomy C. The colostomy has had no output D. The stoma appears dark purple in color

Correct Answer is D

Explanation

Rationale:

A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected postoperatively and should be managed, but it does not indicate an immediate threat to tissue viability or life. It is not the top priority when compared to signs of stoma compromise.

B. The client refuses to look at the colostomy: Emotional adjustment is important and should be addressed with sensitivity, but it is a psychosocial concern rather than a physiological emergency. This can be prioritized after physical complications are ruled out.

C. The colostomy has had no output: Absence of output within the first 24 hours may be related to bowel manipulation during surgery. While it should be monitored, it is not as urgent as signs suggesting stoma necrosis or ischemia.

D. The stoma appears dark purple in color: A dark purple stoma indicates poor perfusion or possible necrosis, which is a surgical emergency. A healthy stoma should appear pink or red and moist. Immediate intervention is required to preserve tissue viability.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following Interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

Correct Answer is D

Explanation

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