In reviewing the medical record for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area in the accompanying figure where the nurse will assess for this change.
Epigastrium
Umbilical
Flank
Subumbilical
The Correct Answer is B
Rationale:
A. Epigastrium refers to the upper central region of the abdomen, just below the sternum; Cullen’s sign does not appear here.
B. Umbilical region (around the navel) is where Cullen’s sign appears as a bluish discoloration due to subcutaneous fat necrosis or retroperitoneal bleeding associated with acute pancreatitis. This is the correct site.
C. Flank discoloration is known as Grey Turner’s sign, another indicator of retroperitoneal bleeding, but distinct from Cullen’s sign.
D. Subumbilical refers to the area below the umbilicus, not the typical site for Cullen’s sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Delaying discussion until after signing the consent form does not address the client’s immediate anxiety or provide needed education.
B. Providing information about sedation reassures the client that discomfort during the colonoscopy will be minimized and helps reduce anxiety. It is accurate, therapeutic, and informative.
C. Acknowledging the recommendation without addressing the anxiety does not provide reassurance or information about pain management.
D. While humorous, this comment does not address the client’s concern about pain and is not considered a therapeutic response.
Correct Answer is C
Explanation
Rationale:
A. Increasing hydration is important for preventing dehydration but does not restore gut flora.
B. Doxycycline is an antibiotic and would worsen disruption of gut microbiota.
C. Lactobacillus acidophilus (a probiotic) helps restore normal intestinal flora balance after antibiotic-associated diarrhea.
D. Psyllium husk is a fiber supplement that aids in bowel regularity but does not restore microbial balance.
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