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. The infant was born large for gestational age: Being large for gestational age is not recognized as a risk factor for child maltreatment. Risk factors are more often related to family dynamics, age, and social stressors rather than birth weight alone.
B. The infant has otitis media: Otitis media, or a middle ear infection, is a common pediatric illness and is not itself a risk factor for maltreatment. It reflects normal childhood health issues rather than abuse or neglect.
C. The infant is younger than 1 year of age: Infants under 1 year are particularly vulnerable to maltreatment because of their total dependence on caregivers and inability to communicate effectively. This age group is at the highest risk for serious injury from abuse.
D. The infant's guardians are both over the age of 30: Parental age over 30 does not inherently increase the risk for child maltreatment. Other factors like substance abuse, history of being abused, and high stress levels are more closely linked to maltreatment risk.
Correct Answer is B
Explanation
A. Reviewing client education: Reviewing education is often part of the termination phase, where teaching is reinforced and the nurse ensures the client understands care plans after the therapeutic relationship ends. It is not a primary focus during the working phase.
B. Identifying problem-solving skills: The working phase focuses on active problem-solving, setting goals, and implementing strategies to address the client's issues. This is when trust is established further, and the nurse and client collaborate on interventions and coping techniques to promote positive outcomes.
C. Summarizing the goals and objectives achieved: Summarizing achievements is part of the termination phase, when the nurse and client reflect on progress made. It helps bring closure to the relationship but does not belong to the working phase where the focus is still on active progress.
D. Specifying a contract: Specifying a contract is a task of the orientation phase, where the structure of the nurse-client relationship, roles, and expectations are defined. This lays the foundation before entering into the problem-solving focus of the working phase.
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