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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Rationale:
- Monitor for elevated temperature: Epidural anesthesia can mask symptoms of infection such as chorioamnionitis. Monitoring temperature helps detect early signs of infection or epidural-related complications.
- Assess for urinary retention: Epidural anesthesia often causes loss of bladder sensation, increasing the risk for urinary retention. Regular assessments are needed to determine when catheterization is required.
- Assist the client with ambulation: After epidural anesthesia, lower limb motor function may be impaired. Ambulation is unsafe due to the risk of falls and injury; bedrest is generally advised until full motor function returns.
- Inform the client to expect drowsiness: Drowsiness is not a typical side effect of epidural anesthesia; it may indicate systemic absorption or another issue. Encouraging drowsiness may mask concerning symptoms that need prompt evaluation.
- Encourage the client to turn from side to side: Repositioning helps maintain optimal uteroplacental perfusion and prevents hypotension caused by vena cava compression from aortocaval syndrome.
Correct Answer is D
Explanation
Rationale:
A. First trimester bleeding: Abruptio placentae typically occurs in the third trimester, not the first. First trimester bleeding is more commonly associated with conditions like miscarriage or ectopic pregnancy.
B. Nausea: Nausea is a non-specific symptom of pregnancy and not a hallmark of abruptio placentae. It does not help distinguish this condition from other obstetric complications.
C. Delayed menses: Delayed menses is an early sign of pregnancy, not a finding related to abruptio placentae. It occurs long before the placenta forms and has no diagnostic value in placental abruption.
D. Severe abdominal pain: Abruptio placentae involves premature separation of the placenta from the uterine wall, leading to intense, persistent abdominal pain, uterine tenderness, and often vaginal bleeding. It is a medical emergency requiring immediate intervention.
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