A nurse is collecting data from a client who has acute pancreatitis. Which of the following findings should the nurse expect?
Pain relieved by the prone position
Decreased WBC count
Hyperactive bowel sounds
Epigastric pain
The Correct Answer is D
A. Pain relieved by the prone position: Pain from acute pancreatitis is typically not relieved by lying prone. Clients often find some relief by sitting up, leaning forward, or assuming a fetal position, as these positions reduce pressure on the inflamed pancreas.
B. Decreased WBC count: Acute pancreatitis usually triggers an inflammatory response, leading to an elevated white blood cell (WBC) count, not a decreased one. Leukocytosis is a common laboratory finding associated with the body's reaction to inflammation and possible infection.
C. Hyperactive bowel sounds: In acute pancreatitis, bowel sounds are often decreased or absent due to paralytic ileus. Hyperactive bowel sounds would be more suggestive of other gastrointestinal disturbances such as diarrhea or early intestinal obstruction.
D. Epigastric pain: Severe, persistent epigastric pain that may radiate to the back is the hallmark symptom of acute pancreatitis. This pain is typically sudden in onset and worsens after eating or drinking, especially fatty foods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I have switched from tobacco cigarettes to electronic cigarettes.": Although electronic cigarettes may reduce exposure to certain harmful chemicals found in tobacco smoke, they still pose significant health risks. This change does not reflect truly limiting risky behavior but rather substituting one form of risk for another.
B. "Sometimes I am exposed to toxic chemicals at my workplace, but not any that have harmed me.": Exposure to toxic chemicals, even without immediate harm, still represents ongoing risk. A proactive approach would involve using protective equipment or seeking safer work conditions.
C. "Two of my grandparents had diabetes, so I try to eat a healthy diet.": Actively modifying diet in response to a family health history shows a positive, preventative approach and reflects conscious efforts to limit risk-taking behaviors and promote long-term health.
D. "My job and home life are both very stressful, but I haven't been able to do anything about that.": Chronic unmanaged stress is a health risk, and acknowledging stress without taking steps to manage it indicates that the client is not effectively limiting risk behaviors.
Correct Answer is A
Explanation
A. Monitor the client for 1 hr after meals: Clients with anorexia nervosa are at high risk for purging behaviors such as vomiting or excessive exercise after meals. Monitoring them for at least 1 hour post-meal helps prevent these behaviors and supports the therapeutic goal of safe weight restoration.
B. Allow the client 2 hr to finish meals: Allowing 2 hours to complete meals is too long and may encourage food avoidance behaviors. Structured meal times with limits (usually around 30 to 45 minutes) are important to establish routine eating habits and prevent manipulation of eating times.
C. Weigh the client every 2 days: Clients with anorexia nervosa are typically weighed daily, often at the same time each morning, to closely monitor weight trends and assess the effectiveness of the treatment plan. Monitoring every 2 days may miss rapid changes that require immediate intervention.
D. Check the client's vital signs two times per week: Vital signs should be checked daily in clients with anorexia nervosa, especially early in treatment, because of the risks of bradycardia, hypotension, and hypothermia. Infrequent monitoring can delay recognition of life-threatening physiological instability.
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