The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the relevance of these symptoms?
The client needs a muscle relaxant.
The client has a nutritional imbalance.
The client is experiencing a reaction to morphine.
The client may be developing hypocalcemia.
The Correct Answer is D
Choice A reason: Administering a muscle relaxant addresses the symptom of muscle twitching and jerking, but it does not identify or treat the underlying cause. For patients with acute pancreatitis, muscle twitching and jerking could be indicative of a more serious condition.
Choice B reason: While a nutritional imbalance could potentially lead to symptoms like muscle twitching and jerking, in the context of acute pancreatitis, the nurse should consider more specific causes related to the condition. Nutritional imbalances do not usually explain these symptoms in patients with pancreatitis as well as hypocalcemia does.
Choice C reason: A reaction to morphine could include various symptoms such as itching, nausea, or constipation, but muscle twitching and jerking are not common side effects. The nurse should consider other causes related to the patient's condition of acute pancreatitis.
Choice D reason: Hypocalcemia, or low calcium levels, is a common complication of acute pancreatitis. It can lead to symptoms such as muscle twitching and jerking, as calcium is crucial for proper muscle function and nerve signaling. This makes hypocalcemia the most relevant and accurate interpretation of the patient's symptoms in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Monitoring amylase and lipase levels is the best way to determine the effectiveness of treatment in a patient with pancreatitis. These enzymes are produced by the pancreas, and their levels in the blood increase significantly during an episode of pancreatitis. As treatment progresses and the inflammation of the pancreas decreases, the levels of these enzymes should return to normal. Therefore, checking the levels of amylase and lipase is a direct indicator of the patient's response to treatment.
Choice B reason: Hematocrit and hemoglobin levels are important for assessing overall blood volume and oxygen-carrying capacity, but they are not specific indicators of pancreatitis treatment effectiveness. While these levels can provide information about the patient's general health and hydration status, they do not specifically reflect changes in pancreatic inflammation.
Choice C reason: Red blood cell count is another measure of the blood's oxygen-carrying capacity and overall health, but like hematocrit and hemoglobin, it is not specific to pancreatitis. Changes in red blood cell count can occur due to various factors, but they do not provide direct information about the effectiveness of pancreatitis treatment.
Choice D reason: Serum uric acid levels are typically monitored in conditions such as gout or kidney stones, and they are not related to pancreatitis. Monitoring serum uric acid would not provide useful information about the patient's response to pancreatitis treatment.
Correct Answer is A
Explanation
Choice A reason: An increase in urine output to 35 mL/hr is the best indication of improved perfusion. Urine output is a direct measure of kidney function and perfusion. When the kidneys receive adequate blood flow, they are able to produce urine. An increase in urine output indicates that the patient's kidneys are being perfused more effectively, which is a reliable sign of overall improved perfusion status.
Choice B reason: A decrease in heart rate to 105 beats/min is a positive sign, as it indicates a reduction in the stress response and an improvement in hemodynamic status. However, it is not as direct an indicator of improved perfusion as urine output. Heart rate can be influenced by many factors, and while a lower heart rate is generally a good sign, it does not specifically indicate improved organ perfusion.
Choice C reason: An increase in systolic blood pressure to 85 mmHg is an indication of improved hemodynamic stability, but it is not as sensitive a measure of perfusion as urine output. Blood pressure provides information about the pressure within the arteries but does not directly indicate how well the organs and tissues are being perfused.
Choice D reason: A decrease in right atrial pressure is not typically an indicator of improved perfusion. Right atrial pressure reflects the pressure in the right atrium of the heart, which can be influenced by various factors, including fluid status and cardiac function. It is not a direct measure of perfusion to vital organs and tissues.
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