The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?
Hepatorenal failure.
Acute pancreatitis.
Surgical site infection.
Biliary duct obstruction.
The Correct Answer is B
Choice A reason: This is incorrect because hepatorenal failure is a condition that involves both liver and kidney dysfunction, usually as a complication of cirrhosis or portal hypertension. The symptoms of hepatorenal failure may include jaundice, ascites, edema, oliguria, or encephalopathy. However, these are not consistent with the client's presentation of fever, abdominal pain, vomiting, and elevated amylase and lipase levels.
Choice B reason: This is correct because acute pancreatitis is an inflammation of the pancreas that can be caused by gallstones, alcohol abuse, trauma, infection, or drugs. The symptoms of acute pancreatitis may include fever, upper abdominal pain that radiates to the back, nausea, vomiting, and elevated amylase and lipase levels. These are consistent with the client's presentation and suggest that the cholecystectomy may have triggered an attack of acute pancreatitis.
Choice C reason: This is incorrect because surgical site infection is an infection that occurs at or near the incision site after surgery. The symptoms of surgical site infection may include redness, swelling, warmth, pus drainage, or pain at the wound site. However, these are not consistent with the client's presentation of fever, abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels.
Choice D reason: This is incorrect because biliary duct obstruction is a blockage of the bile ducts that carry bile from the liver and gallbladder to the intestine. The causes of biliary duct obstruction may include gallstones, tumors, inflammation, or scarring. The symptoms of biliary duct obstruction may include jaundice, dark urine, pale stools, itching, or abdominal pain. However, these are not consistent with the client's presentation of fever, abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
Choice B reason: Left-sided facial drooping and dysphagia are common signs of right hemisphere stroke, but they do not require immediate intervention by the nurse. The nurse should monitor the patient's swallowing ability and provide oral care.
Choice C reason: Orientation to person and place only is a sign of impaired cognition, which is also common in right hemisphere stroke. The nurse should assess the patient's memory, judgment, and attention span.
Choice D reason: Unequal bilateral hand grip strengths are a sign of hemiparesis, which is a weakness on one side of the body. The nurse should assist the patient with mobility and prevent contractures.
Correct Answer is C
Explanation
Choice A reason: Restriction of caloric intake is not a good change for a client with diabetes mellitus and an upper respiratory infection, because it can lead to hypoglycemia and malnutrition. The client needs adequate calories to maintain blood glucose levels and support immune function. Therefore, this choice is incorrect.
Choice B reason: Fewer fingerstick glucose checks are not a good change for a client with diabetes mellitus and an upper respiratory infection, because they can lead to poor blood glucose control and complications. The client needs frequent monitoring of blood glucose levels to adjust insulin doses and prevent hyperglycemia or hypoglycemia. Therefore, this choice is incorrect.
Choice C reason: Higher doses of insulin are a good change for a client with diabetes mellitus and an upper respiratory infection, because they can help lower blood glucose levels and prevent ketoacidosis. The client needs more insulin to overcome the increased insulin resistance caused by the infection and the stress hormones. Therefore, this choice is correct.
Choice D reason: Increased oral fluid intake is a good change for a client with diabetes mellitus and an upper respiratory infection, but it is not directly related to blood glucose management. The client needs more fluids to prevent dehydration and clear mucus from the respiratory tract. Therefore, this choice is not the best answer.
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