A patient with acute pancreatitis begins to demonstrate confusion and agitation. Which of the following does this information suggest to the nurse?
1. increasing intracranial pressure and efforts need to be implemented immediately to reduce the pressure
2. an acute cerebral vascular accident is imminent
3. confusion is because of an increase in serum ammonia and efforts need to be implemented to reduce this level
4. neurological changes are common and further assessment should be done with the Glasgow Coma scale
4
Rationale: The patient with acute pancreatitis frequently develops an alteration in level of consciousness. The nurse can rapidly trend the state of arousal using the Glasgow Coma Scale. Common neurologic manifestations include confusion, restlessness, and agitation. Confusion and agitation in this patient do not indicate increasing intracranial pressure nor an acute cerebral vascular accident. Increased serum ammonia levels are not associated with pancreatic dysfunction but rather hepatic dysfunction.
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