The nurse is assessing a client with acute pancreatitis.
Which finding requires the most immediate intervention
by the nurse?
A.
The client's amylase level is three times higher than the
normal level.
B.
The client has a carpal spasm when taking a blood
pressure.
C.
On a 1 to 10 scale, the client tells the nurse that her
epigastric pain is at 7.
D.
The client states that she will continue to drink alcohol
after going home. -CORRECT ANSWER B
The nurse is assessing a client with acute pancreatitis.
Which finding requires the most immediate intervention
by the nurse?
,Rationale:A positive Trousseau sign indicates
hypocalcemia and always requires further assessment
and intervention, regardless of the cause (40% to 75% of
those with acute pancreatitis experience hypocalcemia,
which can have serious, systemic effects). A key
diagnostic finding of pancreatitis is serum amylase and
lipase levels that are two to five times higher than the
normal value. Severe boring pain is an expected
symptom for this diagnosis, but dealing with the
hypocalcemia is a priority over administering an
analgesic. Long-term planning and teaching do not have
the same immediate importance as a positive Trousseau
sign.
A 55-year-old male client has been admitted to the
hospital with a medical diagnosis of chronic obstructive
pulmonary disease (COPD). Which risk factor is the most
significant in the development of this client's COPD?
A.
The client's father was diagnosed with COPD in his 50s.
B.
,A close family member contracted tuberculosis last year.
C.
The client smokes one to two packs of cigarettes per day.
D.
The client has been 40 pounds overweight for 15 years. -
CORRECT ANSWER C
Rationale:Smoking, considered to be a modifiable risk
factor, is the most significant risk factor for the
development of COPD. The exact mechanism of genetic
and hereditary implications for the development of COPD
is still under investigation, although exposure to similar
predisposing factors (e.g., smoking or inhaling
secondhand smoke) may increase the likelihood of COPD
incidence among family members. Options B and D do
not exceed the risks associated with cigarette smoking in
the development of COPD.
In assessing a client diagnosed with primary
aldosteronism, the nurse expects the laboratory test
, results to indicate a decreased serum level of which
substance?
A.
Sodium
B.
Phosphate
C.
Potassium
D.
Glucose -CORRECT ANSWER C
Rationale:Clients with primary aldosteronism exhibit a
profound decline in serum levels of potassium;
hypokalemia; hypertension is the most prominent and
universal sign. The serum sodium level is normal or
elevated, depending on the amount of water resorbed
with the sodium. Option B is influenced by parathyroid
hormone (PTH). Option D is not affected by primary
aldosteronism.
Which finding requires the most immediate intervention
by the nurse?
A.
The client's amylase level is three times higher than the
normal level.
B.
The client has a carpal spasm when taking a blood
pressure.
C.
On a 1 to 10 scale, the client tells the nurse that her
epigastric pain is at 7.
D.
The client states that she will continue to drink alcohol
after going home. -CORRECT ANSWER B
The nurse is assessing a client with acute pancreatitis.
Which finding requires the most immediate intervention
by the nurse?
,Rationale:A positive Trousseau sign indicates
hypocalcemia and always requires further assessment
and intervention, regardless of the cause (40% to 75% of
those with acute pancreatitis experience hypocalcemia,
which can have serious, systemic effects). A key
diagnostic finding of pancreatitis is serum amylase and
lipase levels that are two to five times higher than the
normal value. Severe boring pain is an expected
symptom for this diagnosis, but dealing with the
hypocalcemia is a priority over administering an
analgesic. Long-term planning and teaching do not have
the same immediate importance as a positive Trousseau
sign.
A 55-year-old male client has been admitted to the
hospital with a medical diagnosis of chronic obstructive
pulmonary disease (COPD). Which risk factor is the most
significant in the development of this client's COPD?
A.
The client's father was diagnosed with COPD in his 50s.
B.
,A close family member contracted tuberculosis last year.
C.
The client smokes one to two packs of cigarettes per day.
D.
The client has been 40 pounds overweight for 15 years. -
CORRECT ANSWER C
Rationale:Smoking, considered to be a modifiable risk
factor, is the most significant risk factor for the
development of COPD. The exact mechanism of genetic
and hereditary implications for the development of COPD
is still under investigation, although exposure to similar
predisposing factors (e.g., smoking or inhaling
secondhand smoke) may increase the likelihood of COPD
incidence among family members. Options B and D do
not exceed the risks associated with cigarette smoking in
the development of COPD.
In assessing a client diagnosed with primary
aldosteronism, the nurse expects the laboratory test
, results to indicate a decreased serum level of which
substance?
A.
Sodium
B.
Phosphate
C.
Potassium
D.
Glucose -CORRECT ANSWER C
Rationale:Clients with primary aldosteronism exhibit a
profound decline in serum levels of potassium;
hypokalemia; hypertension is the most prominent and
universal sign. The serum sodium level is normal or
elevated, depending on the amount of water resorbed
with the sodium. Option B is influenced by parathyroid
hormone (PTH). Option D is not affected by primary
aldosteronism.
