A nurse in a medical-surgical unit is caring for a client.
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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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Monitor the client's vital signs every hour following the procedure: Vital signs, especially blood pressure, should be monitored more frequently—usually every 5 to 15 minutes immediately after epidural initiation—to assess for hypotension, a common complication.
B. Review the client's platelet count level prior to the procedure: A low platelet count increases the risk of epidural hematoma during needle insertion. Reviewing coagulation status is essential to ensure it's safe to proceed with epidural placement.
C. Inform the client that their bladder should be full before the procedure: The bladder should be emptied, not full, prior to the procedure. A full bladder increases discomfort, impairs fetal descent, and may lead to urinary retention after the epidural is placed.
D. Obtain the client's consent following the procedure: Informed consent must be obtained before any invasive procedure, including epidural anesthesia. Performing the procedure without prior consent violates patient autonomy and legal standards.
Correct Answer is B
Explanation
Rationale:
A. Chlordiazepoxide: Chlordiazepoxide is a benzodiazepine used primarily to manage alcohol withdrawal symptoms. It has no direct role in smoking cessation and is not commonly prescribed for nicotine dependence.
B. Bupropion: Bupropion is an atypical antidepressant approved for smoking cessation. It reduces nicotine cravings and withdrawal symptoms by acting on the brain’s norepinephrine and dopamine pathways, making it an effective choice for clients trying to quit.
C. Naltrexone: Naltrexone is an opioid antagonist used to treat opioid and alcohol dependence. It does not target nicotine addiction and is not indicated for smoking cessation therapy.
D. Clonidine: Clonidine is occasionally used off-label to manage withdrawal symptoms, including those from nicotine. However, it is not a first-line medication for smoking cessation and is less commonly prescribed for this purpose.
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