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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 A

Explanation

Rationale:

A. “The client exhibits impulsive behavior.” Impulsivity is a hallmark trait of borderline personality disorder (BPD). Clients may engage in risky behaviors such as substance abuse, binge eating, or reckless driving, often in response to emotional instability and fear of abandonment.

B. “The client is overly concerned about minor details.” This behavior is more characteristic of obsessive-compulsive personality disorder, where clients show perfectionism and a rigid adherence to rules, order, and control over details.

C. “The client might act seductively.” Seductive or provocative behavior is commonly seen in histrionic personality disorder. These clients seek attention and approval through exaggerated emotional expression and flirtatiousness.

D. “The client is exceptionally clingy to others.” Clinginess and an excessive need to be taken care of are features of dependent personality disorder. These individuals have difficulty making decisions independently and fear separation or rejection.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

Rationale for Correct Choices:

Decreased cardiac output: The client is post–myocardial infarction and experiences chest pain with minimal exertion, tachycardia (HR 112/min), and signs of anxiety and fear. These findings suggest that myocardial function may be compromised. Decreased cardiac output is a significant risk in post-MI clients due to potential for reinfarction, ischemia, or left ventricular dysfunction.
Respiratory failure: The client has COPD, an elevated respiratory rate (32/min), and oxygen saturation of 87% on room air, which indicates significant hypoxemia. The productive cough, fatigue, and shortness of breath increase the risk for decompensation into respiratory failure without prompt oxygen therapy and pulmonary support.

Rationale for Incorrect Choices:

Pancytopenia: This condition involves a reduction in red blood cells, white blood cells, and platelets. There is no evidence of bone marrow suppression, recent chemotherapy, or hematologic disorder in this client’s history.
Neurogenic shock: Neurogenic shock results from spinal cord injury or disruption of sympathetic nervous system control. The client has no evidence of trauma or spinal pathology, and the elevated heart rate contradicts the expected bradycardia of neurogenic shock.
Hepatic encephalopathy: This is caused by liver dysfunction, typically in clients with advanced liver disease. There are no signs of altered mental status, liver disease, or elevated ammonia levels in this case.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

Correct Answer is A

Explanation

A nurse on a step-down unit is admitting a client. Exhibits Drag words from the choices below to fill in each blank in the follow sentence. The client is at risk for developing dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

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