Pancreatitis NCLEX (ATI, Evolve, Lewis, Success)

Nursing management of the patient with acute pancreatitis includes: (SATA) A. Check for signs of hypocalcemia B. Provide a diet low in carbohydrates C. Giving insulin based on sliding scale D. Observing stools for signs of steatorrhea E. Monitoring for infection, particularly respiratory tract infection

A, E Rationale: During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Injection fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek's sign or Trousseau's sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.

A nurse is completing nutritional teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (SATA) A. I plan to eat small, frequent meals. B. I will eat easy-to-digest foods with limited spice C. I will use skim milk when cooking D. I plan to drink regular cola E. I will limit alcohol intake to two drinkers per day

A,B C Rationale: Patients with pancreatitis should eat small, frequent, easy to digest, low-fat meals. Pt should avoid alcohol and caffeinated beverages.

The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? A. Recommend lying in the prone position with legs extended B. Maintain a tripod position over the bedside table C. Plance in side-lying position with knees flexed D. Encourage a supine position with a pillow under the knees

C Rationale: The fetal position deceases pain caused by the stretching of the peritoneum as a result of edema. The pancreas is located abdomen. Anything that causes the abdomen to be stretched will increase pain.

The client is diagnosed with acute pancreatitis. What health-care provider's admitting order should the nurse question? A. Bedrest with bathroom privileges B. Initiate IV therapy of D5W at 125 mL/hr C. Weight client daily D. Low fat, low car diet

D Rationale: Bedrest decreases the metabolic rate. The client should be NPO to rest the pancreas to decrease the auto digestion of the pancreas. Since the client is NPO IV therapy is appropriate. Weight changes will happen as a result of diet and IV fluids therefore daily weights is appropriate.

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? A. Pain in the UQ rating to the shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to the left shoulder

D. Rationale: A client with pancreatitis will report pain being worse when lying down in the fetal position, and pain that radiates to the back. left flank, or left, shoulder.

A nurse is completing the admission assessment of a client who has acute pancreatitis. Which finding is the first priority? A) History of cholelithiasis B) Elevated serum amylase levels C) Decrease in bowel sounds upon auscultation D) Hand spasms present when blood pressure is checked

D. Rationale: the greatest risk to the client is ECG changes and hypotension from hypocalcemia. Hand spasms when taking blood pressure is a manifestation of hypocalcemia

The nurse is caring for a 55-yr-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect? A) Hematochezia B) Left upper abdominal pain C) Ascites and peripheral edema D) Temperature over 102 F

B Rationale: Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

The client diagnosed with acute pancreatitis is being discharged home. What statement by the client indicates the teaching has been effective? A. I should decrease my intake of coffee, tea, and cola B. I will eat a low fate diet and avoid spicy food C. I will check my amylase and lipase levels daily D. I will return to work tomorrow but take it easy

B Rationale: High fat and spicy foods stimulate pancreatic enzymes. Caffeinated beverages should be avoided not decreased. There are no daily tests the client can take at home. The client will be fatigued as a result as a lowered metabolic rate and will need to rest.

What client problem has a priority for the client diagnosed with acute pancreatitis? A. Risk for fluid volume deficient B. Alteration in comfort C. Imbalanced nutrition: less than the boy requires D. Knowledge deficient

B. Rationale: Autodigestion of the pancreas results in severe pain, accompanied by nausea, vomiting,m abdominal tenderness, and muscle guarding. The Maslow's hierarchy should be applied. After ABC's pain is the next priority

A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care? A) Immediately start enteral feeding to prevent malnutrition. B) Insert an NG and maintain NPO status to allow pancreas to rest. C) Initiate early prophylactic antibiotic therapy to prevent infection. D) Administer acetaminophen (Tylenol) every 4 hours for pain relief.

B. Rationale: Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

A nurse is assessing a client who has pancreatitis. Which of the following actions should the nurse take to assess the presence of Cullen's sign. A. Tap lightly at the costovertebral margin on the client's back B. Palpate the RLQ C. Inspect the skin around the umbilicus D. Auscultate the area below the scapula

C. Rationale: Cullen's sign is indicated by a bluish-gray discoloration in the periumbillical area

The client is admitted to the medical department with a diagnosis of R/O acute pancreatitis. What laboratory values should the nurse monitor to confirm this diagnosis? A. Creatinine and BUN B. Troponin and CK-MB C. Serum amylase and lipase D. Serum bilirubin and calcium

C. Rationale: Serum amylase levels increase within two to 12 hours of the onset of acute pancreatitis; lipase elevates and remains elevated for seven to 14 days

The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. What instruction should the nurse discuss with the client? A. Instruct the importance to avoid all stress B. Explain the correct way to take pancreatic enzymes C. Instruct the client to decrease alcohol intake D. Discuss the importance of stopping smoking

D. Rationale: Alcohol must be avoided completely due to its destruction of the pancreas. Stress stimulates the liver, but it is unrational to avoid all stress. Pancreatic enzymes are only needed for chronic pancreatitis. Smoking stimulates the pancreas to release pancreatic enzymes.