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 ["0.5"]
Explanation
Step 1 is (10 mg ÷ 20 mg/mL) = 0.5 mL. The nurse should administer 0.5 mL per dose. .
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale
Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.
Choice B rationale
Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.
Choice C rationale
Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.
Choice E rationale
Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.
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