Acute Pancreatitis Exam with Rationales Graded A 2025

1. 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 2. 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. 3. 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 4. 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 Acute Pancreatitis Exam with Rationales Graded A 2025 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. 5. 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). 6. 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.