A nurse in an urgent care facility is caring for a client.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Belief in being reunited with the child is a common and healthy coping mechanism.
B. Inability to experience joy (anhedonia) is a key symptom of major depressive disorder and warrants further assessment.
C. Feeling guilty is a normal part of grief but does not necessarily indicate major depression.
D. Anger is a normal stage of grief and does not typically indicate a disorder unless prolonged or extreme.
Correct Answer is A
Explanation
A. Glargine insulin is a long-acting insulin that provides consistent basal glucose control for up to 24 hours.
B. NPH insulin is intermediate-acting, not long-acting.
C. Regular insulin is short-acting, used for meal coverage or acute hyperglycemia.
D. Insulin aspart is rapid-acting, used for postprandial glucose control.
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