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 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.
Correct Answer is D
Explanation
A. Informing the client about pharmacological pain management contradicts her decision for a natural childbirth.
B. Encouraging family to leave during pain is unnecessary and may reduce support, which is essential for coping during labor.
C. Breathing techniques are helpful, but exhaling deeper than inhaling may not be appropriate for ventilation; rhythmic breathing is typically encouraged.
D. Hydrotherapy (such as warm baths or showers) is a natural pain management technique that can promote relaxation and decrease labor pain.
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