NGN Adult Health Gastrointestinal/Nutrition
The nurse is conducting a telephone call following up with a client with a colostomy placed two weeks ago ➢ Click to highlight the findings reported by the client that require follow-up by the nurse Nurses' Note The client reports that he has no pain at the stoma. He states that the stoma is red and moist. He reports changing the appliance daily He reports using moisturizing soap around the stoma. The client notes that he empties the pouch when it is one-half to one-third full of stool. The client stated that his stoma has been getting smaller in size since surgery. Submit Answer
Explanation A stoma should appear beefy red, and moist. This finding indicates adequate perfusion to the stoma. Stomas that are purple, blue, black, and dry are concerned for lack of blood flow. The appliance should not be changed daily. This will cause the client to run out of supplies, and the constant changing of the appliance will increase the risk of skin irritation. The appliance should be changed every 3-5 days. Moisturizing soap should not be used around the stoma because this decreases adherence to the appliance to the skin. It is recommended that a mild soap be utilized and the hair around the area be clipped. It is appropriate that the pouch is emptied when it is one-half to one-third full. Considering this client is two weeks post-operative, the edema should decrease, and the stoma will reach its normal size within six to eight weeks following surgery. Additional Info ✓ Teaching a client about ostomy management may be extensive, and it would be appropriate for the nurse to refer the client to a certified wound and ostomy nurse. ✓ Skin care is a significant priority for a client with an ostomy device. ✓ The client should use mild soap, ensure that the peristomal skin is dry before applying the appliance, and clip (not shave) the surrounding hair. ✓ If peristomal skin becomes raw (skin stripping), stoma powder, paste, or a combination may also be applied.
The following scenario applies to the next 1 times The nurse is caring for a client who presents with acute appendicitis Item 1 of 1 History Of Present IllnessVital SignsLaboratory Results 19-year-old female admitted with abdominal pain localized to the right lower quadrant. The onset of pain was twelve hours ago, and the client now reports pain is worsening when the client coughs. Endorses nausea and has persistent vomiting. Oral temperature 101° F (38.3°C) Pulse 90/minute Respirations 18/minute Blood Pressure 110/66 mm Hg Oxygen saturation 96% on room air White blood cell count, 11,500 mm3 (5,000-10,000 mm3) Creatinine, 0.9 mg/dL (0.6-1.2 mg/dL) BUN 26 mg/dL (10-20 mg/dL) Potassium 3.3 mEq/L (3.5-5 mEq/L) ➢ Select two (2) findings from the clinical data that require immediate follow-up Oral temperature 101° F (38.3° C) White blood cell count, 11,500 mm³ Creatinine, 0.9 mg/dL Nausea and vomiting Potassium 3.3 mEq/L BUN 26 mg/dL Reports of pain increasing while coughing Submit Answer
Explanation Clinical features and expected findings of appendicitis include - Right lower quadrant pain that may refer to the left lower quadrant Rebound tenderness in the right lower quadrant Anorexia Nausea and vomiting Leukocytosis Fever An expected finding with appendicitis is the client having an elevated white blood cell (WBC) count. If the WBC count should exceed 20,000 mm3, this may indicate a perforation. A fever, nausea, and vomiting are expected and do not require follow-up. The elevated BUN at 26 mg/dL is expected as dehydration is a common occurrence. The client's hypokalemia is concerning as this is a consequence of vomiting. Thus, the nurse needs to follow up on this finding with the primary healthcare provider (PHCP). Finally, increased pain while the client coughs indicate that the appendix has perforated. Additional Info Nursing care for a client with suspected appendicitis includes establishing intravenous access, initiating nothing-by-mouth (NPO) status, and administering prescribed antibiotics, fluids, and pain medication. The client with suspected appendicitis should not have heat applied to the affected area.
5-10 The following scenario applies to the next 6 times The nurse in the emergency department cares for a client with abdominal pain and vomiting Item 1 of 6 History And PhysicalVital Signs 56-year female arrives at the emergency department (ED) after reporting persistent vomiting overnight, described as bright red blood. She reports mid-epigastric pain that is worsened when she eats. She rates the pain as an 8 out of 10, described as burning. Her bowel sounds are active in all four quadrants, and no abdominal distention was noted. She endorses nausea. She appears pale with dry skin. The client is alert and fully oriented. Her medical history includes osteoarthritis in her hips and knees, alcohol use disorder, hypothyroidism, and generalized anxiety disorder. She states that her knees have caused her so much pain she has been less physically active the past two weeks. She reports smoking one pack of cigarettes per day and denies alcohol use. Her current medications include daily use of naproxen which she reports increased usage because of knee pain, levothyroxine, and citalopram. She recently started taking over-the-counter omeprazole three days ago for an unspecified reason. Oral Temperature 98o F (36.7o C) Pulse 107/minute Respirations 19/minute Blood pressure 101/68 mm Hg Oxygen saturation 95% on room air ➢ Which two (2) client findings in the history and physical are most concerning? Select all that apply. Mid-epigastric pain Vomiting bright red blood Current daily smoker History of hypothyroidism History of generalized anxiety disorder Active bowel sounds Submit Answer ➢ Which factor best explains the client's findings? Select all that apply. Increased naproxen use Worsening knee pain Physical inactivity Starting omeprazole History of alcoholism Submit Answer ➢ Complete the following sentences from the list of options The client has most likely developed necrotizing pancreatitis/ peptic ulcer disease/ small bowel obstruction The nurse should immediate take action to reduce the nausea/ decrease the abd pain/ restore the vol to prevent the most serious complication of hyperglycemia/ hypovolemic shock/ esophageal erosion Submit Answer The nurse is developing the plan of care for this client. ➢ For each possible order or prescription from the primary healthcare provider (PHCP), click to indicate if it is anticipated or not anticipated Possible order or prescription from the PHCPAnticipatedNot Anticipated Establish a vascular access device Administer intravenous (IV) pantoprazole Prepare the client for a barium enema Obtain the client's hemoglobin and hematocrit (H&H) Administer intravenous (IV) ketorolac Insertion of a nasogastric tube (NGT) Submit Answer Orders Insert two peripheral vascular access devices Infuse two units of packed red blood cells Pantoprazole 40 mg, IV Morphine 4 mg, IV Insert nasogastric tube (NGT) The nurse obtains laboratory data, orders, and prescriptions from the primary healthcare provider ➢ Select three (3) appropriate interventions the nurse should take when preparing to administer packed red blood cells (PRBCs) Insert a 22-gauge vascular access device Obtain the client's weight Infuse the PRBCs over two to four hours Obtain y-type tubing with filter Verify the unit of blood with unlicensed assistive personnel Remain with the client for the hour of infusion Change the tubing between each unit of PRBCs Submit Answer The nurse educates the client about the transfusion of packed red blood cells (PRBCs) ➢ Which manifestations should the nurse instruct the client to report during the PRBC transfusion? Select all that apply Low back pain Shortness of breath Chills Thirst Apprehension Itching Submit Answer
Explanation Concerning findings in the H&P, include the client's mid-epigastric pain and reports of vomiting blood. These findings require follow-up because they are acute findings compared to the client's chronic conditions of hypothyroidism, anxiety, and tobacco use. Finally, active bowel sounds are not an abnormal finding and do not require follow-up. Explanation The clinical findings of mid-epigastric pain and hematemesis can best be explained by the client's increased naproxen usage and her alcohol use disorder. Naproxen is a non-steroidal anti-inflammatory drug (NSAID) and directly contributes to gastrointestinal irritation and, worse, gastrointestinal bleeding. The alcohol use disorder causes significant gastrointestinal irritation and contributes to the client's clinical presentation of abdominal pain and hematemesis. Explanation The client is most likely experiencing peptic ulcer disease (PUD) based on the client's significant mid-epigastric pain and hematemesis, which are classic gastric ulcer symptoms. Necrotizing pancreatitis would cause abdominal pain but not hematemesis. Small bowel obstruction is excluded because it does not cause hematemesis. The priority is to restore the client's volume status as the client has tachycardia which is indicative of hypovolemia. Restoring the client's volume will help prevent hypovolemia shock, which will likely be complications if volume status is not addressed. Explanation Anticipated prescriptions and orders would include the nurse establishing peripheral vascular access in anticipation of administering intravenous pantoprazole (proton pump inhibitor), isotonic fluids, and pain medication. The client's H&H should be obtained to determine the severity of the client's anemia. The insertion of an NGT is likely because it may be used to lavage the stomach and aspirate gastrointestinal contents, if necessary. Explanation When transfusing a unit of PRBCs, the nurse should establish vascular access of at least a 20-gauge to prevent hemolysis during the transfusion and the transfusion should be administered over two to four hours. The unit of PRBCs should be administered in a y-type infusion set that has a filter. The client, unit of blood, and prescription should be verified with another nurse, not a UAP. Once the transfusion is initiated, the nurse should remain with the client for the first fifteen minutes to observe for a hemolytic reaction, which is the most catastrophic. If multiple units of blood are administered, new tubing should be used each time to prevent septicemia. Obtaining the client's weight is not necessary for administering a unit of blood. Explanation The nurse should educate the client about manifestations of a transfusion reaction, including low back pain, apprehension, rash, fever, chills, apprehension, and itching. Thirst is not a manifestation associated with a transfusion reaction.
The following scenario applies to the next 1 times The nurse is caring for a 44-year-old male with abdominal pain and persistent nausea/vomiting Item 1 of 1 History Of Present IllnessVital SignsLab Results 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. Oral temperature 99.0o F (37o C); Pulse 119 bpm; Respirations 22; BP 90/58 mm Hg; O2 saturation 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. Action to Take Parameters to Monitor Potential Conditions Action to Take Parameters to Monitor Action to Take Obtain a prescription of 0.9% saline bolus Inquire about the client's alcohol drinking habits Obtain a prescription for regular insulin Establish peripheral intravenous (IV) access Transport the client for an abdominal computed tomography (CT) scan Potential Conditions Acute Pancreatitis Peptic Ulcer Disease Diverticulitis Peritonitis Gastroenteritis Parameters to Monitor Level of Consciousness (LOC) Bowel Sounds Vital Signs Serum Glucose Level Daily Weights Submit Answer
Explanation Potential Conditions The client is most likely experiencing acute pancreatitis. The client's history of present illness stated that the client has persistent nausea and vomiting, epigastric abdominal pain, worsening pain with palpation, and bruising around the umbilicus. These manifestations coincide with acute pancreatitis. The client with acute pancreatitis will have hyperglycemia, leukocytosis, and significant dehydration. The ecchymosis around the umbilicus is highly concerning as this is strongly suggestive of necrotizing pancreatitis. Peritonitis does cause abdominal pain that is diffuse and not localized to the epigastric area. Further, peritonitis is infectious and causes a high fever. This client does not have these findings, nor do they have findings of constant lower left quadrant pain suggestive of diverticulitis. Action to Take An immediate priority for a client experiencing acute pancreatitis is repleting the lost fluids. The client's vital signs show hypovolemic shock (hypotension; tachycardia), and this requires the nurse to promptly establish intravenous access and obtain a prescription for 0.9% saline bolus. The client is dealing with necrotizing pancreatitis that has caused hypovolemic shock. Transporting the client to a CT scan is not safe, considering the client's instability. Inquiring about the client's alcoholism will not impact the hypovolemic shock that the client is experiencing and should be delayed until the client is stable. Hyperglycemia is expected with acute pancreatitis and is caused by the inability of the pancreas to secrete insulin because of inflammation. Correcting the glucose level is important but not the priority considering the hypovolemic shock. Parameters to Monitor The parameters to monitor for a client experiencing hypovolemic shock caused by acute pancreatitis are vital signs and consciousness level. If the client responds favorably to the saline bolus, the heart rate will decrease, and the client will become normotensive. The level of consciousness needs to be monitored to determine if the client deteriorates neurologically. If the client fails to respond, the nurse should collaborate with the primary healthcare provider (PHCP) for more aggressive fluid replacement. Once the client has stabilized from the shock, the nurse can monitor the bowel sounds, daily weights, and blood glucose. However, these monitoring parameters are not applicable for mitigating hypovolemic shock. Additional Info Acute pancreatitis may be caused by cholelithiasis, severe hyperlipidemia, alcoholism, and trauma. The clinical manifestations and nursing care for acute pancreatitis are found in the tables below. Acute pancreatitis picture
11-16 The following scenario applies to the next 6 times 15-year-old female presents to the emergency department with abdominal pain Item 1 of 6 Nurses' NoteVital SignsAssessment 1945 - 15-year-old female reported abdominal pain that started this morning and has worsened. Her parents indicated that she had a temperature of 100o F (37.8o C) earlier in the day and that acetaminophen did not decrease the pain or temperature. She reports anorexia, nausea, and started vomiting two hours ago. The client describes her abdominal pain as a constant cramp in the right lower side. She states that her pain increases when she coughs. The client has no medical history and takes no medication. She does report being sexually active with no birth control. Oral Temperature 102o F (38.9o C) Pulse 88/minute Respirations 18/minute Blood pressure 121/72 mm Hg Oxygen saturation 96% on room air ➢ Which assessment finding requires immediate follow-up? The client's temperature sexual activity. nausea and vomiting. pain increasing with coughing. Submit Answer ➢ For each client finding below, click to specify if it is consistent with cholecystitis, pregnancy, or appendicitis. Each finding may support more than one condition. Each column must have at least one response option selected. Client FindingAppendicitisPregnancyCholecystitis Nausea and vomiting Periumbilical abdominal pain Fever Anorexia Submit Answer ➢ Complete the sentences below from the list of options The nurse is most concerned that the client has paralytic ileus/ ruptured appendix/ possible pregnancy because pain that is worsened with coughing/ of her reported sexual activity Submit Answer Diagnostics Abdominal Ultrasound: Perforated Appendix with free intraperitoneal fluid noted The physician orders an abdominal ultrasound and laboratory tests The nurse reviews the results and plans interventions for this client ➢ For each possible intervention, click to specify if the intervention is indicated or not indicated InterventionIndicatedNot Indicated Obtain peripheral vascular access Administer broad spectrum antibiotics Obtain blood cultures Prepare the client for a barium enema Place the client on nothing-by-mouth (NPO) status Submit Answer The nurse obtains a prescription from the physician for 50 mcg of intravenous (IV) push fentanyl ➢ Complete the sentences below from the list of options Prior to administering the fentanyl, the nurse should obtain VS/ Blood gluc/ ROM After administering the medication and prior to leaving the room, the nurse should raise the clients upper side rails/ apply nasal cannula O2/ verify the clients name and DOB Submit Answer The physician orders the client to go to surgery for a laparoscopic appendectomy. The physician obtains the client's informed consent from her parents. The nurse provides education regarding this surgery. ➢ Which two (2) client statements indicate that the client needs further post-operative education? I'm looking forward to going to school tomorrow. I need to turn and do deep breathing exercises. I will only be able to have clear liquids for one week. If I experience pain, I will have pain medication prescribed. I may feel bloated and have abdominal distention. I will need to ambulate if I experience cramping. Submit Answer
Explanation Signs of appendix rupture include pain increasing with coughing or sudden pain relief. A fever is expected with appendicitis, along with nausea and vomiting. While the client's sexual activity requires follow-up concerning a potential pregnancy, this is not life-threatening, whereas ruptured appendicitis leads to septic shock. Explanation Many overlapping features exist between appendicitis and cholecystitis. Both cause nausea & vomiting, fever, and anorexia. The pain differs where appendicitis causes more periumbilical pain, and cholecystitis causes pain in the right upper quadrant that radiates to the upper scapula. Pregnancy only shares the early manifestation of nausea and vomiting. Abdominal cramping may be associated with early pregnancy signs, but not abdominal pain localized to the periumbilical area. Nausea and vomiting123 Periumbilical abdominal pain1 Fever13 Anorexia13 Submit Answer Explanation The nurse is most concerned about a ruptured appendix because it is the most life-threatening and the most likely diagnosis based on the client's increased pain with coughing, guarding of the abdomen, and fever. Paralytic ileus is unlikely because the client's localized abdominal pain and no abdominal distention were noted in the assessment. Her sexual activity would not be an immediate concern even if pregnancy was possible because it would not lead to immediate complications. Explanation The client has a high white blood cell count, making it concerning for peritonitis. Her HCG is negative, which excludes pregnancy. For a client with a ruptured appendix, it is essential that the nurse obtain immediate peripheral vascular access, obtain blood cultures, administer broad spectrum antibiotics, and place the client on NPO status because of their likely surgery. A barium enema is not indicated in the treatment or diagnosis of acute appendicitis as it has no relevance. Explanation Before administering fentanyl, an opioid analgesic, the nurse should assess the client's vital signs and ensure that the client does not have bradypnea or hypotension. Both of which would contraindicate the administration of an opioid. Blood glucose and range of motion are not relevant to the administration of fentanyl. Before leaving the client's room, the nurse should institute fall precautions involving raising the client's upper side rails. Applying nasal cannula oxygen is not indicated after administering an opioid. To promote client safety, verifying the client's name and date of birth should occur before administering the medication. Explanation Following a laparoscopic procedure, the client will need a recovery period of up to one week. The client going to school tomorrow is not realistic and requires follow-up. The client's diet will be advanced per the physician and will be advanced over a couple of days - not weeks. Laparoscopic procedures involve the process of insufflation to visualize organs. Gastric distention and cramping are common and mitigated with ambulation. Pain medication will be prescribed after this surgery, and to prevent complications such as pneumonia; the client will need to turn and perform deep breathing exercises.
The following scenario applies to the next 1 times The nurse is caring for a client immediately following an abdominal paracentesis Item 1 of 1 Procedure Note 1845 - Emergency ultrasound-guided abdominal paracentesis was performed because the client presented with labored respirations, dyspnea, abdominal cramping, and overall discomfort. Informed consent was obtained, and the client agreed to the procedure. Prior to the procedure, the client emptied their bladder. The site was cleaned and numbed with 1% lidocaine, and using an aseptic technique and an ultrasound; a 14-gauge catheter was inserted to remove 10 mL of clear ascitic fluid. Subsequently, the fluid was drained via tubing. 6 liters of fluid were removed. The client tolerated the procedure well and reported immediate relief in the dyspnea and abdominal cramping following the procedure. The nurse reviews the procedure note and plans care for the client ➢ Complete the sentences below from the list of options Immediately following this procedure, the nurse should monitor the client's culture and sensitivity results/ BP/ Uurinary output because the client has the risk of punctured bladder/ hypotension/ peritonitis If the client should experience this immediate post-procedure complication, the nurse should anticipate a prescription for albumin/ ceftriaxone/ metronidazole Submit Answer
Explanation The client had six liters of fluid drained from their peritoneal cavity. This is a significant volume (any volume > 5 liters is considered a large abdominal paracentesis). The rapid fluid removal could cause a fluid shift; therefore, the nurse should be prepared to monitor the client for post-procedure hypotension. This hypotension can be treated by infusing prescribed albumin, a colloid. This colloid will restore intravascular fluid volume, which shifted during the procedure. Infection is a concern associated with the procedure. However, it would not be an immediate post-procedure complication. The client emptied their bladder before this procedure, significantly decreasing the likelihood of bladder trauma. Additional Info Abdominal paracentesis is performed for clients with gross ascitic fluid due to liver cirrhosis. Nursing care for an abdominal paracentesis includes - ➢ Witnessing informed consent that the primary healthcare provider obtains ➢ Assisting the client to void before the procedure ➢ Obtaining baseline vital signs ➢ Measure the abdominal girth ➢ Gather appropriate supplies (suction, tubing, paracentesis kit) ➢ Position the client per the physician's prescription. The positioning is likely upright to allow the fluid to settle in the lower abdominal quadrants. ➢ Monitor the client and the drainage ➢ Send the initial ascitic fluid to the lab for culture and sensitivity, as prescribed ➢ Reposition the client, as needed to facilitate better drainage ➢ Monitor the client's vital signs throughout and after the procedure ➢ Administer an infusion of albumin, as prescribed for large volume (> 5 liters) paracentesis
The following scenario applies to the next 1 times The emergency department (ED) nurse is caring for a client with liver cirrhosis Item 1 of 1 Nurses' NoteVital SignsMedical History 57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact. Oral Temperature 101 o F (38.3o C) Heart rate 94/minute Respirations 24/minute Blood pressure 104/68 mm Hg Oxygen saturation 95% on room air Hepatitis C Liver cirrhosis Substance use disorder Hyperlipidemia ➢Which assessment findings require follow-up? Jaundice Labored breathing Hypoactive bowel sounds Respiratory rate Oral temperature Yellow sclera Submit Answer
Explanation The client's labored breathing, tachypnea, and oral temperature are of serious concern. A complication of liver cirrhosis is spontaneous bacterial peritonitis (SBP) which occurs when the ascitic fluid is infected. The infection comes from bacteria that have migrated from the bowel that has entered the lymphatic system. The risk for this potentially fatal infection is increased when an excessive amount of ascitic fluid is evident. The client's temperature being elevated is highly suggestive of this infection. Finally, the client's labored breathing and tachypnea may be a result of the ascites, or it could be related to the potential SBP the client may be experiencing. Either way, these findings require follow-up. The client's jaundice and yellowing of the eyes is an expected finding because of the cirrhosis, and it does not require follow-up. Hypoactive bowel sounds are unremarkable and do not require follow-up.
The following scenario applies to the next 1 times The nurse is caring for a client in the outpatient clinic Item 1 of 1 Nurses' NoteMedical History 35-year-female arrives at the clinic for reported loss of appetite and nausea. The client reports that she is not eating as much because she experiences palpitations, sweating, and dizziness about thirty minutes after she eats. She reports that she has not been adherent to the prescribed diet and her symptoms worsen when she eats something sweet and drinks cola. Morbid obesity (BMI 42) Roux-en-Y procedure eight weeks ago ➢ Complete the following sentence by choosing from the list of options To prevent pernicious anemia/ dumping syndrome/ gastrix reflux the nurse should instruct the client lie down after meals/ stay upright/ exercise after meals and avoid drinking with meals/ eat food high in carbs/ eat food high in vit b12 Submit Answer
Explanation The client's symptoms are consistent with dumping syndrome. This is a common complication following gastric bypass. Dumping syndrome is characterized by rapid emptying of food contents into the small intestine, which shifts fluid into the gut, causing abdominal distention. The nurse should instruct the client to lie down after meals to mitigate symptoms because this will slow gastric emptying. It would also be correct for the nurse to instruct the client to avoid drinking with meals because this accelerates gastric emptying. Pernicious anemia may develop following gastric bypass, but the manifestations would include paresthesia, glossitis, and memory impairments. Additional Info Dumping syndrome is a common complication following gastric bypass surgery. Early dumping syndrome has a rapid onset, usually within 15 minutes. It is the result of rapid emptying of food into the small bowel. Due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in hypotension and a sympathetic nervous system response. Clients often present with colicky abdominal pain, diarrhea, nausea, and tachycardia. At worst, the client runs the risk of hypoglycemia.
19-24 The following scenario applies to the next 6 times The nurse cares for a 55-year-old male in the emergency department (ED) Item 1 of 6 Nurses' NotesVital Signs 1300 - Client was brought to the ED by his wife because of his persistent vomiting and worsening abdominal pain. The client's wife reports that he was out drinking a large amount of alcohol the previous night, and the pain started shortly after. Upon assessment, the client was alert and completely oriented. Lung sounds were clear bilaterally. The client was actively vomiting a large amount of opaque fluid. The clients' peripheral pulses were intact and thready. Capillary refill was less than three seconds. His abdomen was distended, he had hypoactive bowel sounds in all quadrants and significant tenderness in the epigastric area following palpation. He reports his abdominal pain as '8' on a scale from 0-10. The client has no medical history and has an allergy to ceftriaxone with an unknown reaction. Oral Temperature 98o F (36.7o C) Pulse 105/minute Respirations 25/minute Blood pressure 95/51 mm Hg Oxygen saturation 96% on room air ➢ Which two (2) client findings require follow-up by the nurse? Pulse rate Capillary refill Epigastric tenderness Lung sounds Client orientation Medication allergy Submit Answer ➢ For each client finding below, click to specify if the client finding is consistent with the disease process of appendicitis, pancreatitis, or cholecystitis. Each finding may support more than one disease process. Client FindingsAppendicitisPancreatitisCholecystitis Nausea and Vomiting Epigastric tenderness Signs of dehydration Pain triggered by alcohol intake Submit Answer ➢ Complete the following sentence by choosing from the list of options If the nurse does not intervene, the client runs the highest risk for delirium tremens/ hypovolemic shock/ perforation as evidenced by the client's alcoholism/ increasing and pain/ VS Submit Answer The nurse has reviewed the nurses' notes from 1300 ➢ The nurse should plan to take which appropriate interventions? Select all that apply Establish peripheral vascular access Obtain a prescription for intravenous fluid bolus Establish continuous cardiac monitoring Prepare the client for an arterial blood gas (ABG) Request a prescription for oral pain medication Provide the client with a selection of oral fluids Submit Answer Orders Establish large-bore peripheral vascular access device Two liters of 0.9% saline bolus over one hour Computed tomography (CT) scan of the abdomen and pelvis Fentanyl 100 mcg intravenous (IV) push Obtain capillary blood glucose Nurses notes 2 1350 - Called to the bedside by the client's wife. The client reported that his heart was 'racing' and had projectile vomiting. Peripheral pulse rate was 110 beats/minute and thread. The client reported their pain as a '4' on a scale 0-10. The nurse has implemented all the physician orders for this client and reviews the 1350 nursing note entry located on nurses' note (2) ➢ For each assessment finding, specify if the finding has improved, unchanged, or declined Assessment FindingImprovedUnchangedDeclined Pain '4' on a scale 0-10 Thready peripheral pulses Projectile vomiting Pulse 110/minute Submit Answer
The follow-up findings are the client's pulse rate and epigastric tenderness. The client is experiencing tachycardia and significant epigastric tenderness. The other findings are within normal limits (or not concerning). Explanation Overlapping features of appendicitis, pancreatitis, and diverticulitis include abdominal pain, dehydration, and nausea/vomiting. A gallstone or alcoholism may trigger pancreatitis. Additionally, pancreatitis may cause a client to have epigastric or left upper quadrant tenderness. Because all three conditions feature nausea and vomiting, dehydration is highly likely in all the conditions. Nausea and Vomiting123 Epigastric tenderness23 Signs of dehydration123 Pain triggered by alcohol intake2 Explanation Although this client did ingest alcohol, he is alert and completely oriented, and delirium tremens are not a concern. Perforation is a concern associated with appendicitis - not a complication common with pancreatitis. The client's vital signs are concerning because he is exhibiting signs of hypovolemic shock. This life-threatening complication of acute pancreatitis calls for aggressive fluid repletion. Explanation Considering that this client is tachycardic and reporting that his heart is 'racing,' the nurse needs to immediately act and establish vascular access, obtain a prescription for intravenous fluids, and initiate continuous cardiac monitoring to monitor the client's pulse. An ABG is not necessary since this client is not endorsing any dyspnea. While he does have tachypnea, it is likely from the pain. Oral pain medication and oral fluids would be contraindicated as the client should be kept nothing by mouth (NPO). Explanation Establishing peripheral vascular access and initiating the prescribed saline bolus is essential. The client is tachycardic and his heart rate is increasing. Thus, calls for the nurse to act. It is imperative for the nurse to medicate the client for their pain, but pain medication will not resolve the tachycardia that the client is experiencing. A CT scan will help diagnose pancreatitis, and hyperglycemia is likely with acute pancreatitis, but these do not prioritize the client's need for rapid fluid repletion. Explanation The client's pain has decreased, which signifies an improvement. His thready pulse has been unchanged since the initial assessment. His pulse rate has increased, which shows a decline in his condition. The client has projectile vomiting, which has declined from the simple vomiting that the client experienced prior. Additional Info Acute pancreatitis may cause hypovolemic shock, and the client should be resuscitated with isotonic intravenous fluids once a diagnosis is made to prevent this complication. Pancreatitis may be triggered by cholelithiasis or alcoholism. This disorder commonly causes a client to experience intense epigastric pain, nausea/vomiting, and sometimes jaundice.
The following scenario applies to the next 1 times The nurse is caring for an older adult in the medical-surgical unit Item 1 of 1 Health HistoryVital Signs 84-year-old female was admitted to the medical-surgical unit with a three-day history of abdominal pain, distention, nausea, and persistent vomiting. She reports that she has not had a bowel movement in five days and has no appetite. Oral temperature 101.1° F (38.3° C) Pulse 108/minute Respirations 22/minute Blood pressure 100/64 mm Hg Oxygen saturation 96% on room air. The nurse reviews the client's health history and vital signs ➢ Click to specify if the findings are consistent with a small bowel obstruction or appendicitis. Each row must have at least one but may have more than one response option selected Clinical FindingsSmall Bowel ObstructionAppendicitis Unable to pass stool Fever Distended abdomen Right lower quadrant abdominal pain Nausea and vomiting
Unable to pass stool1 Fever12 Distended abdomen1 Right lower quadrant abdominal pain2 Nausea and vomiting12 Explanation Clinical features of a small bowel obstruction and appendicitis can be found in the below table - Treatment for a small bowel obstruction involves operative or non-operative management. Nursing care involves establishing vascular access and rehydrating the client, as prescribed. Intravenous pain medication and nothing-by-mouth (NPO) status will likely be prescribed.
