Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?
Pancreatic pseudocyst.
Electrolyte imbalance.
Internal bleeding.
Pleural effusion.
The Correct Answer is C
Choice A rationale
Pancreatic pseudocyst is a complication of acute pancreatitis, but it is not directly associated with Cullen’s sign. Cullen’s sign indicates periumbilical ecchymosis, which is a sign of internal bleeding.
Choice B rationale
Electrolyte imbalance can occur in acute pancreatitis, but it is not indicated by Cullen’s sign. Cullen’s sign specifically points to internal bleeding.
Choice C rationale
Internal bleeding is the correct answer. Cullen’s sign is a bluish discoloration around the umbilicus, indicating bleeding within the abdomen. This can occur in severe cases of acute pancreatitis due to hemorrhage.
Choice D rationale
Pleural effusion can be a complication of acute pancreatitis, but it is not indicated by Cullen’s sign. Cullen’s sign is specific to internal bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.
Choice B rationale
Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.
Choice C rationale
Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.
Choice D rationale
Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.
Correct Answer is D
Explanation
Choice A rationale
Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.
Choice B rationale
The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.
Choice C rationale
Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.
Choice D rationale
Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.
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