49. A client is admitted with acute pancreatitis after a holiday celebration including excessive food and alcohol. Which assessment finding reflects this diagnosis?
49. A client is admitted with acute pancreatitis after a holiday celebration including excessive food and alcohol. Which assessment finding reflects this diagnosis?
. Hyperactive bowel sounds.
. Sudden onset of continuous epigastric and back pain.
. Moist crackles in both lung fields.
. Elevated temperature and BP.
Test-Taking Tip
Pancreatitis = Pain (e.g., Answer 2 is an acute inflammatory reaction); therefore Answers 1, 3, and 4 would not apply. Although there may be an elevated temperature (Answer 4), elevated BP would not occur.
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is incorrect because bowel sounds in acute pancreatitis are usually diminished or absent. Answer 2 is correct because the autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric and/or back pain reflect the inflammatory process in the pancreas. Answer 3 is incorrect because breath sounds may be decreased or absent from atelectasis or pleural effusion. Answer 4 is incorrect because the client becomes hypotensive, not hypertensive, due to shock. The temperature becomes elevated because of the acute inflammatory reaction.