You complete your admission assessment and note the following abnormalities: B.K. is restless and alert,lying on her right side in a semifetal position
Assessment findings are as follows: skin is cool, diaphoretic,
and pale with poor skin turgor; mucous membranes are dry. Heart rhythm is regular, rate 96, without murmurs or rubs. Peripheral pulses are faintly palpable in four extremities. Respiration rate 24, but unlabored
on 2 L O
2/NC with spo2 90%. Breath sounds are absent in lower left lobe (LLL) posteriorly—otherwise,
clear to auscultation throughout. she complains of nausea and is having dry heaves. Bowel sounds are
hypoactive. Abdomen is distended, firm, and tender in a diffuse fashion to light palpation, with guarding
noted.
Your institution uses electronic charting. Based on the assessment given, which of the
following systems would you mark as "abnormal" as you document your findings? Mark
abnormal findings with an X and provide a brief narrative.
X Abnormal
? Neurologic
? Respiratory
? Cardiovascular
? Gastrointestinal
? Genitourinary
? Musculoskeletal
? Skin
? Psychosocial
? Pain
? Neurologic: Restless and alert, lying on her right side in a semifetal position.
? Respiratory: Respirations rapid, rate 24, unlabored on 2 L O2/NC with Spo2 90%. Breath sounds are
absent in LLL posteriorly.
? Cardiovascular: Peripheral pulses are faintly palpable in four extremities.
? GI: Complains of nausea; having dry heaves. Bowel sounds hypoactive. Abdomen distended, firm,
and tender in a diffuse fashion to light palpation, with guarding noted.
? Genitourinary:
? Musculoskeletal:
? Skin: Skin cool, diaphoretic, and pale with poor skin turgor; mucous membranes are dry.
? Psychosocial:
? Pain:
Which specific laboratory results point to a diagnosis of pancreatitis?
The lipase and amylase levels are extremely high; in addition, the liver function study (ALP, ALT, AST)
values and total bilirubin are elevated, which also points to pancreatitis along with liver disease. The
low albumin level might be decreased with inflammation, stress, or liver disease. The elevated WBCs
might reflect inflammation.
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The student nurse studying the digestive system knows that most of the work of absorption occurs through a system of villi and folds in the:
A) stomach. B) gall bladder. C) small intestine. D) large intestine.
Which action is an accepted tactic when engaged in a negotiation?
A) Being willing to win at any cost B) Communicating only when asked direct questions C) Compromising only as a last resort D) Beginning with a high but realistic expectation
Which situation is least likely to place severe, disabling stress on a family? The
a. need for long-term care for a man with a wife and two teenage sons who sustains severe brain injury. b. divorce of the parents of three children, aged 10, 8, and 2 years. c. death of a mother who leaves a husband and three sons younger than 12 years. d. family in which the son leaves for college and the father retires.
While tapping the facial nerve on the right side of a client's face, the nurse notes twitching on the same side. This assessment finding may indicate which electrolyte imbalance?
1. Hypomagnesemia 2. Hyponatremia 3. Hyperkalemia 4. Hypercalcemia