What does the nurse recognize as clinical manifestations consistent with ascites? Select all that apply.

Stretch marks

Foul-smelling breath

Increased abdominal girth

Visible distended veins

Rapid weight gain

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Stretch marks, also known as striae, are not specific to ascites. They can occur due to rapid weight gain or loss, pregnancy, or other conditions that cause the skin to stretch. While they may be present in individuals with ascites due to rapid abdominal expansion, they are not a primary clinical manifestation of ascites.

Choice B reason: Foul-smelling breath, or halitosis, is not a typical symptom of ascites. It can be associated with various conditions, including poor oral hygiene, gastrointestinal disorders, or liver disease, but it is not a direct indicator of ascites.

Choice C reason: Increased abdominal girth is a primary clinical manifestation of ascites. Ascites is characterized by the accumulation of fluid in the peritoneal cavity, leading to noticeable abdominal distension. This symptom is often accompanied by a feeling of fullness or bloating.

Choice D reason: Visible distended veins, particularly around the abdomen, can be a sign of ascites. This occurs due to increased pressure in the abdominal veins as a result of fluid accumulation. The veins become more prominent and visible under the skin.

Choice E reason: Rapid weight gain is another key indicator of ascites. The accumulation of fluid in the abdomen leads to a significant increase in body weight over a short period. This rapid weight gain is often one of the first signs that prompts further investigation for ascites.

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Correct Answer is ["C","E"]

Explanation

Choice A: Formed stool in collection pouch

Formed stool in the collection pouch is not expected in an ileostomy. The output from an ileostomy is typically liquid to semi-liquid because the ileum does not absorb as much water as the colon. If formed stool is present, it may indicate a blockage or other issue that needs to be addressed.

Choice B: Stoma is edematous and bleeding

An edematous and bleeding stoma is not a normal finding and may indicate complications such as infection, trauma, or poor stoma care. The stoma should be moist and pink, but not swollen or bleeding. Persistent bleeding or significant edema should be reported to a healthcare provider immediately.

Choice C: Stoma is pink and shiny

A pink and shiny stoma is a sign that the ileostomy is functioning well. This indicates good blood flow and healthy tissue. The stoma should always appear moist and pink, similar to the inside of the mouth. Any deviation from this appearance, such as a pale, dark, or dry stoma, should be evaluated by a healthcare professional.

Choice D: Skin excoriation around the stoma

Skin excoriation around the stoma is not a normal finding and suggests that the skin is being irritated by the stoma output or the ostomy appliance. Proper skin care and fitting of the ostomy appliance are essential to prevent skin breakdown. If excoriation occurs, it should be treated promptly to prevent further complications.

Choice E: Mucus liquid flows from the stoma

Mucus liquid flowing from the stoma is expected in an ileostomy. The output is typically liquid to semi-liquid and may contain mucus, which is normal for the small intestine. This type of output indicates that the ileostomy is functioning as intended.

A. Increased serum amylase B. Increased serum calcium C. Decreased WBC D. Decreased serum lipase

Correct Answer is A

Explanation

Choice A Reason:

Increased serum amylase is a key indicator of acute pancreatitis. Amylase is an enzyme produced by the pancreas to help digest carbohydrates. In cases of acute pancreatitis, the pancreas becomes inflamed, leading to the release of amylase into the bloodstream. Elevated levels of serum amylase, typically more than three times the upper limit of normal, are a strong indication of acute pancreatitis. This enzyme level usually rises within a few hours of the onset of pancreatitis and can remain elevated for several days.

Choice B Reason:

Increased serum calcium is not typically associated with acute pancreatitis. In fact, acute pancreatitis can often lead to hypocalcemia (low calcium levels) due to fat saponification in the pancreas, where calcium binds with fatty acids. Therefore, an increase in serum calcium would not be expected in a patient with acute pancreatitis. Monitoring calcium levels is important, but an increase is not a diagnostic marker for this condition.

Choice C Reason:

Decreased WBC (white blood cell count) is not a characteristic finding in acute pancreatitis. On the contrary, acute pancreatitis often leads to an elevated WBC count due to the inflammatory response in the body. Leukocytosis (increased WBC) is a common finding in many inflammatory and infectious conditions, including acute pancreatitis. Therefore, a decreased WBC count would not be expected and does not support the diagnosis of acute pancreatitis.

Choice D Reason:

Decreased serum lipase is incorrect. Similar to amylase, lipase is another enzyme produced by the pancreas, which helps in the digestion of fats. In acute pancreatitis, serum lipase levels also increase significantly, often more than three times the upper limit of normal. Lipase levels tend to rise slightly later than amylase but remain elevated for a longer period, making it a useful marker for diagnosing acute pancreatitis. Therefore, decreased serum lipase would not be expected in this condition.

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What does the nurse recognize as clinical manifestations consistent with ascites? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with an ileostomy because of inflammatory bowel disease. Which assessment findings indicate to the nurse that the ileostomy is functioning as expected? Select all that apply.

Correct Answer is ["C","E"]

Explanation

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

Correct Answer is A

Explanation

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