A nurse in an urgent care facility is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Pancreatitis

Rationale:

The client's presentation with severe upper left quadrant abdominal pain, nausea, febrile status, tachypnea, and increased amylase and lipase levels suggests pancreatitis. Pancreatitis commonly presents with abdominal pain, nausea, and vomiting (though vomiting is not reported here), and elevated pancreatic enzymes (amylase and lipase). The elevated glucose level (200 mg/dL) may also point to pancreatitis since the pancreas plays a role in glucose metabolism.

Actions to Take:

Administer opioids for pain:

Rationale: Pain management is crucial in pancreatitis. Administering opioids like morphine or hydromorphone can help manage the severe pain, improving comfort and reducing distress.

Maintain separate equipment for the client:

Rationale: In cases of pancreatitis, particularly if caused by an infectious etiology, it is essential to avoid cross-contamination. Separate equipment reduces the risk of spreading infections if relevant.

Parameters to Monitor:

Dyspnea:

Rationale: The patient is tachypneic, and it's important to monitor for any progression of respiratory issues. Dyspnea could indicate worsening respiratory status or complications such as pleural effusion.

Hypotension:

Rationale: Hypotension can be a sign of shock, a potential complication of pancreatitis due to fluid loss, or systemic inflammatory response. It is important to monitor for signs of hypotension to ensure adequate perfusion and prevent shock.

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Correct Answer is A

Explanation

A. Crackles in the lungs are a common finding in heart failure due to pulmonary congestion and fluid accumulation.

B. Decreased thirst is not typically associated with heart failure.

C. Tachycardia can occur in heart failure but is not as specific as crackles for diagnosing fluid overload.

D. Poor skin turgor is more indicative of dehydration, not heart failure.

A. Respirations easy and unlabored B. Right forearm and fingers are edematous C. Ecchymotic area noted on outer aspect of the forearm D. Radial pulse +2 E. Fingers slightly cool to touch F. mild "tingling" sensation G. Child verbalizes a pain level of 4 on a scale of 0 to 10 H. Multiple areas of bruising are noted on lower extremities in various stages of healing I. Oxygen saturation 98% on room air

Correct Answer is ["B","C","E","F","H"]

Explanation

Assessment

Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.

Vital Signs

Temperature 36.8° C (98.2° F)

Heart rate 102/min

Respiratory rate 22/min

BP 100/60 mm Hg

Oxygen saturation 98% on room air

Rationale:

Edema in the right forearm and fingers: The edema, particularly in the right forearm, may indicate a possible fracture or soft tissue injury. This requires immediate follow-up, including further assessment, potential imaging (e.g., X-ray), and intervention to rule out bone fractures, compartment syndrome, or significant tissue damage.

Fingers slightly cool to touch: This could indicate compromised circulation to the fingers, potentially due to swelling or a more serious injury like a fracture causing compression or vascular injury. Immediate follow-up is necessary to assess for any signs of impaired circulation, which could require urgent medical intervention.

Mild "tingling" sensation in the fingers: The tingling sensation might indicate nerve involvement or compression, which could be related to a fracture or soft tissue injury. Immediate follow-up is needed to assess for nerve damage or compartment syndrome, both of which require timely management to prevent long-term damage.

Multiple areas of bruising in various stages of healing: While this finding does not require immediate follow-up in the context of the current injury, it could raise concerns about possible underlying issues such as bleeding disorders or abuse. Although not an immediate concern, this warrants further investigation in the longer term.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

Correct Answer is ["B","C","E","F","H"]

Explanation

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