Nokea
The nurse is assessing a client who has appendicitis. Which of the following would be an expected finding? Select all that apply.
- A. Leukocytosis
- B. Melena
- C. Fever
- D. Nausea and Vomiting
- E. Anorexia
Correct Answer: A,C,D,E
Rationale: Appendicitis commonly presents with leukocytosis (A) due to infection, fever (C) from inflammation, nausea and vomiting (D), and anorexia (E) due to gastrointestinal irritation. Melena (B) is not typically associated with appendicitis.
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The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 2 of 6
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
The nurse is reviewing assessment findings to differentiate between acute pancreatitis and cholecystitis. For each assessment finding below, click to specify if the finding is consistent with the disease process of acute pancreatitis or cholecystitis. Each finding may support more than one (1) disease process. Each column must have at least one (1) response option selected.
- A. Severe epigastric pain
- B. Gray-blue discoloration of the flanks
- C. Nausea and vomiting
- D. Leukocytosis
- E. Elevated lipase and amylase
- F. Hypocalcemia
Correct Answer: A,C,D,E,F;A,C,D
Rationale: Acute pancreatitis: A (Severe epigastric pain), C (Nausea and vomiting), D (Leukocytosis), E (Elevated lipase and amylase), F (Hypocalcemia). Cholecystitis: A, C, D. Elevated lipase/amylase and hypocalcemia are specific to pancreatitis.
The nurse has instructed self-management strategies for a client diagnosed with gastroesophageal reflux disease (GERD). Which statement by the client would indicate a correct understanding of the teaching?
- A. It's much better for me to wear loose-fitting clothes right now.
- B. I stopped eating grilled chicken and now eat more ground hamburger.
- C. If I wake up with GERD symptoms, I should lower the head of my bed while sleeping.
- D. I should take my prescribed omeprazole after meals.
Correct Answer: A
Rationale: Loose-fitting clothes (A) reduce abdominal pressure, helping manage GERD. Hamburger (B) is high-fat and worsens reflux, lowering the bed (C) increases symptoms, and omeprazole (D) is taken before meals.
The following scenario applies to the next 1 items.
The nurse is caring for a 44-year-old male with abdominal pain and persistent nausea/vomiting.
Item 1 of 1
History of Present Illness
Abdominal pain that started one day ago following heavy alcohol use. The pain is localized to the epigastric region. Persistent nausea and vomiting were reported. Physical exam showed ecchymosis around the umbilicus and tenderness upon palpation.
Vital Signs
• Oral temperature 99.0° F (37° C)
• Pulse 119
• Respirations 22
• BP 90/58
• Pulse oximetry 95% on room air
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two priority actions the nurse should take to address that condition, and two priority parameters the nurse should monitor to assess the client's progress.
- A. Obtain a prescription of 0.9% saline bolus, Inquire about the clients alcohol drinking habits, Obtain a prescription for regular insulin, Establish peripheral intravenous (IV) access, Transport the client for an abdominal computed tomography (CT) scan.
- B. Acute Pancreatitis, Peptic Ulcer Disease, Diverticulitis, Peritonitis, Gastroenteritis.
- C. Level of Consciousness (LOC), Bowel Sounds, Vital Signs, Serum Glucose Level, Daily Weights.
Correct Answer: B: Acute Pancreatitis; A: Obtain a prescription of 0.9% saline bolus, Establish peripheral IV access; C: Vital Signs, Level of Consciousness
Rationale: Epigastric pain, nausea/vomiting, and periumbilical ecchymosis suggest acute pancreatitis (B). Saline bolus and IV access (A) address hypovolemia. Monitoring vital signs and LOC (C) tracks hemodynamic stability and complications.
The nurse is reviewing a client's medical record, and it is noted that they have a positive Murphy sign. The nurse recognizes that this sign is elicited in which abdominal quadrant?
- A. Area A
- B. Area B
- C. Area C
- D. Area D
Correct Answer: C
Rationale: Murphy's sign, elicited by pain on palpation of the right upper quadrant (Area C) during inspiration, is associated with cholecystitis.
The nurse is screening individuals at risk for gastric cancer. It would be appropriate for the nurse to identify which of the following as a risk factor for gastric cancer?
- A. Irritable bowel syndrome
- B. Duodenal ulcer
- C. Chronic gastritis
- D. Sickle cell anemia
Correct Answer: C
Rationale: Chronic gastritis (C), often caused by H. pylori, is a known risk factor for gastric cancer. The other options are not directly associated.