1. A client has been admitted to the hospital with a diagnosis of acute pancreatitis
and the nurse is assessing the client's pain. What type of pain is
... [Show More] consistent with
this diagnosis?
a. Burning and aching, located in the left lower quadrant and radiating to the
hip
b. Severe and unrelenting, located in the epigastric area and radiating to the
back
c. Burning and aching, located in the epigastric are and radiating to the
umbilicus
d. Severe and unrelenting, located in the left lower quadrant and radiating to
the groin - Ans: b
The pain associated with acute pancreatitis is often severe and unrelenting, is
located in the epigastric region, and radiates to the back. The other options are
incorrect.
2. The nurse is reviewing the prescription for a client admitted to the hospital with a
diagnosis of acute pancreatitis. Which interventions would the nurse expect to be
prescribed for the client? Select all that apply.
a. Administer antacids as prescribed
b. Encourage coughing and deep breathing
c. Administer anticholinergics as prescribed
d. Give small, frequent high-calorie feedings
e. Maintain the client in a supine and flat position
f. Give meperidine (Demerol) as prescribed for pain. - Ans: a, b, c, f
The client with acute pancreatitis normally is placed on NPO status to rest the
pancreas and suppress gastrointestinal secretions. Because abdominal pain is a
prominent symptom pancreatitis, pain medication such as meperidine is
prescribed. Some clients experience lessened pain by assuming positions that
flex the trunk, with the knees drawn up to the chest. A side-lying position with the
head elevated 45 degrees decreases tension on the abdomen and may help
ease the pain. The client is susceptible to respiratory infections because the
retroperitoneal fluid raises the diaphragm, which causes the client to take
shallow, guarded abdominal breaths. Therefore measures such as turning,
coughing, and deep breathing are instituted. Antacids and anticholinergics may
be prescribed to suppress gastrointestinal secretions.
3. Nursing management of the patient with acute pancreatitis includes (select all
that apply)
a. checking for signs of hypocalcemia.
b. providing a diet low in carbohydrates.
c. giving insulin based on a sliding scale.
d. observing stools for signs of steatorrhea.e. monitoring for infection, particularly respiratory tract infection. - Ans: a, e
4. Which complication of acute pancreatitis requires prompt surgical drainage to
prevent sepsis?
a. Tetany
b. Pseudocyst
c. Plerual effusion
d. Pancreatic abscess - Ans: d
A pancreatic abscess is a collection of pus that must be drained to prevent
infection of adjacent organs and sepsis. Tetany from hupocalcemia is treated
with IV calcium gluconate (10%). Although pseudocysts usually resolve
spontaneously, they may be treated with surgical, percutaneous catheter, or
endoscopic drainage to prevent perforation. Pleural effusion is treated by treating
the cause (pancreatitits) and monitoring for respiratory distress and oxygen
saturation.
5. When assessing a patient with acute pancreatitis, the nurse would expect to find:
a. hyperactive bowel sounds.
b. hypertension and tachycardia.
c. a temperature greater than 102 F (38.9 C).
d. Severe midepigastric or left upper quadrant (LUQ) pain. - Ans: d
the predominant symptom of acute pancreatitis is severe, deep abdominal pain
that is usually located in the left upper quadrant (LUQ) but may be in the
midepigastrium. Bowel sounds are decreased or absent, temperature is elevated
only slightly, and the patient has hypovolemia and may manifest symptoms of
shock. [Show Less]