{"id":136132,"date":"2024-09-10T07:16:48","date_gmt":"2024-09-10T07:16:48","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=136132"},"modified":"2024-09-10T07:16:50","modified_gmt":"2024-09-10T07:16:50","slug":"a-client-with-acute-pancreatitis-has-the-following-assessment","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/10\/a-client-with-acute-pancreatitis-has-the-following-assessment\/","title":{"rendered":"A client with acute pancreatitis has the following assessment"},"content":{"rendered":"\n

A client with acute pancreatitis has the following assessment: abdominal pain 7\/10, nausea and vomiting for 2 days, vital signs: BP 108\/70 mmHg, temperature 99.8\u00b0F, pulse 98 bpm, respiratory rate 22 breaths\/min, inelastic skin turgor, and concentrated urine. Which nursing diagnosis should the nurse select as a priority?<\/p>\n\n\n\n

A.
Impaired elimination.<\/p>\n\n\n\n

B.
Fluid imbalance.<\/p>\n\n\n\n

C.
Fever.<\/p>\n\n\n\n

D.
Nausea.<\/p>\n\n\n\n

The Correct Answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n

The priority nursing diagnosis for this client with acute pancreatitis is B. Fluid imbalance<\/strong>.<\/p>\n\n\n\n

Explanation:<\/h3>\n\n\n\n

Fluid imbalance<\/strong> is the most pressing concern given the client’s symptoms and assessment findings. Acute pancreatitis can lead to significant fluid loss and dehydration due to several factors:<\/p>\n\n\n\n

    \n
  1. Nausea and Vomiting:<\/strong> The client has been experiencing nausea and vomiting for two days. Persistent vomiting can result in considerable fluid and electrolyte loss, leading to dehydration and fluid imbalance.<\/li>\n\n\n\n
  2. Inelastic Skin Turgor:<\/strong> Inelastic skin turgor is a classic sign of dehydration. This finding suggests that the client may be experiencing a deficit in fluid volume, which is consistent with the effects of ongoing vomiting and inadequate fluid intake.<\/li>\n\n\n\n
  3. Concentrated Urine:<\/strong> Concentrated urine is another indicator of dehydration. When the body is dehydrated, urine becomes more concentrated as the kidneys attempt to conserve water.<\/li>\n\n\n\n
  4. Vital Signs and Respiratory Rate:<\/strong> Although the client’s blood pressure (BP) is within normal limits and the pulse is relatively stable, the elevated respiratory rate (22 breaths\/min) can be a compensatory mechanism in response to dehydration or discomfort. Additionally, the slight fever (99.8\u00b0F) might be associated with inflammation or infection, which can further exacerbate fluid loss.<\/li>\n<\/ol>\n\n\n\n

    Impaired elimination<\/strong> (Option A) and nausea<\/strong> (Option D) are important considerations but are secondary to the immediate risk of fluid imbalance. While impaired elimination could be a concern in the broader context of the client’s condition, the most urgent issue is managing the potential fluid deficit.<\/p>\n\n\n\n

    Fever<\/strong> (Option C) is less critical compared to the potential for severe fluid imbalance. Although the client has a mild fever, it is not as immediate a threat as the signs of dehydration and potential fluid loss.<\/p>\n\n\n\n

    Addressing fluid imbalance involves ensuring adequate hydration and monitoring electrolyte levels, which is essential for the client’s overall stability and recovery. Effective management of fluid balance will help address other symptoms and prevent complications related to dehydration.<\/p>\n","protected":false},"excerpt":{"rendered":"

    A client with acute pancreatitis has the following assessment: abdominal pain 7\/10, nausea and vomiting for 2 days, vital signs: BP 108\/70 mmHg, temperature 99.8\u00b0F, pulse 98 bpm, respiratory rate 22 breaths\/min, inelastic skin turgor, and concentrated urine. Which nursing diagnosis should the nurse select as a priority? A.Impaired elimination. B.Fluid imbalance. C.Fever. D.Nausea. The […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-136132","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/136132","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=136132"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/136132\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=136132"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=136132"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=136132"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}