Nursing Elites

1. The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:

• A. Severe and unrelenting, located in the epigastric area and radiating to the back.
• B. Severe and unrelenting, located in the left lower quadrant and radiating to the groin.
• C. Burning and aching, located in the epigastric area and radiating to the umbilicus.
• D. Burning and aching, located in the left lower quadrant and radiating to the hip.

Correct answer: A

Rationale: Acute pancreatitis typically presents with severe, unrelenting pain in the epigastric area that radiates to the back. This pain is due to inflammation and autodigestion of the pancreas.

2. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

• A. A reservoir is created that exits through the abdominal wall.
• B. A second surgery is required 12 months after the first surgery.
• C. A permanent ileostomy is created.
• D. The surgery occurs in two stages.

Correct answer: D

Rationale: The surgery to create an ileoanal reservoir occurs in two stages.

3. Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of feeding for your patient?

• A. TPN
• B. PPN
• C. NG feeding
• D. Oral liquid supplements

Correct answer: C

Rationale: NG feeding is the preferred method for patients with a functioning GI tract but an inability to swallow foods.

4. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

• A. Severe abdominal pain relieved by vomiting
• B. Severe abdominal pain that is unrelieved by vomiting
• C. Hypothermia
• D. Epigastric pain radiating to the neck area

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

5. A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Select the interventions that the nurse would expect to be prescribed for the client.

• A. Small, frequent high-calorie feedings.
• B. Meperidine (Demerol) as prescribed for pain.
• C. Place the client in a side-lying position with the head elevated 45-degrees.
• D. Administer antacids and anticholinergics to suppress gastrointestinal secretions.

Correct answer: B

Rationale: The correct intervention for a client with acute pancreatitis is to prescribe pain medications such as meperidine to manage the abdominal pain, which is a prominent symptom of the condition. The other options are incorrect because: A) Clients with acute pancreatitis are normally placed on NPO (nothing by mouth) status to rest the pancreas, so small, frequent high-calorie feedings are not indicated. C) Placing the client in a side-lying position with the head elevated 45-degrees helps decrease tension on the abdomen and may ease pain, but it is not a standard intervention for acute pancreatitis. D) Administering antacids and anticholinergics to suppress gastrointestinal secretions is not a routine intervention for acute pancreatitis.

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