Difficulty: Medium
Average Score: 87%
Simulated
Passage / Scenario
History and PhysicalDiagnostic Results
Nurses' Notes
Vital Signs.
Day 1
0800:
Client admitted for epigastric abdominal pain. Client rates pain
as 8 on a 0 to 10 scale. Client states pain began 24 hr after
drinking alcohol and eating, a large meal. Client has history of
alcohol use disorder. Client indicated no relief of pain after
taking cimetidine. Client is alert and oriented to person, place and time. Lung sounds diminished in the bases bilaterally. Bowel sounds hypoactive in all four quadrants, abdomen distended. Client reports nausea and vomiting for the past 24 hr
A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immediately to the provider?
Correct answer
A,B,E,F
Rationale
Fever, hypotension, tachycardia, respiratory distress, confusion, and clammy skin indicate worsening pancreatitis or shock.