The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

Activity level of bowel sounds

Eating patterns of dietary intake

Level and amount of physical activity.

Color and consistency of feces.

Answer and Explanation

The Correct Answer is B

A. Activity level of bowel sounds:
Bowel sounds are important to assess, but they may not directly influence or be influenced by the abdominal pain associated with chronic pancreatitis.

B. Eating patterns and dietary intake.
Clients with chronic pancreatitis often experience abdominal pain exacerbated by the intake of food, especially fatty meals. Monitoring the client's eating patterns and dietary intake is crucial for identifying triggers that may worsen the abdominal pain. By understanding the relationship between food intake and pain, the nurse can provide guidance on dietary modifications to help manage the symptoms.

C. Level and amount of physical activity:
While physical activity is important for overall health, it may not be the primary factor contributing to or alleviating the abdominal pain in a client with chronic pancreatitis.

D. Color and consistency of feces:
Monitoring the color and consistency of feces is important for assessing pancreatic function, but it may not be the most immediate factor to address in the context of managing abdominal pain. Dietary patterns are more directly related to pain management in this case.

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Correct Answer is C

Explanation

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema:
This option focuses on assessing perfusion and circulation in the extremities. While it's important in certain situations, in the context of a client who recently underwent cardiac stent placement and is now experiencing chest pressure and shortness of breath, the priority is to assess the cardiac status more directly.

B. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope:
This option involves auscultating the heart for abnormal sounds or rhythms. While it's a valuable assessment in general, in this particular scenario, obtaining an electrocardiogram (ECG) and initiating continuous cardiac monitoring would provide a more comprehensive and immediate evaluation of the cardiac status.

C. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring:
This is the correct choice. Obtaining a 12-lead ECG and initiating continuous cardiac monitoring is crucial in assessing the client's cardiac function. It allows for the detection of any acute changes in the heart's electrical activity or rhythm, which is essential for timely intervention and management.

D. Verify troponin level assessments are scheduled every 3-6 hours for a series of three:
Monitoring troponin levels is important in assessing cardiac damage, but in this acute situation, obtaining an immediate ECG and initiating continuous cardiac monitoring take precedence for a more real-time evaluation of the client's cardiac status. Troponin levels may be monitored subsequently based on the initial findings.

A. Irrigating the catheter manually. B. Monitoring catheter drainage. C. Discontinuing infusing solution. D. Decreasing the flow rate.

Correct Answer is B

Explanation

A. Irrigating the catheter manually:
Manually irrigating the catheter without an order may disrupt the clotting process and increase the risk of bleeding. It is not a routine nursing intervention post-TURP without specific orders.

B. Monitoring catheter drainage.
It is not within the nurse's scope of practice to manually irrigate the catheter without a healthcare provider's order, especially in the context of post-TURP care. The dark, pink-tinged outflow with blood clots indicates some expected bleeding following the procedure. The nurse should closely monitor the catheter drainage for the amount, color, and presence of clots.

C. Discontinuing infusing solution:
Discontinuing the normal saline irrigation may lead to clot formation and obstruction, potentially worsening the situation. The continuous bladder irrigation is often used to prevent clot formation and maintain catheter patency post-TURP.

D. Decreasing the flow rate:
The flow rate is typically set by the healthcare provider to maintain catheter patency and prevent clot formation. Decreasing the flow rate without specific orders may not be appropriate in this situation.

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The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

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Explanation

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Explanation

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