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Zorluk: OrtaReduction of Risk Potential

A nurse is evaluating an adult client admitted with acute pancreatitis who is receiving aggressive intravenous fluid resuscitation. Which of the following clinical findings indicate a developing complication that requires immediate intervention? (Select all that apply)

  1. Carpal spasm occurring when the blood pressure cuff is inflatedCevap
  2. New-onset fine crackles auscultated in the bilateral lung basesCevap
  3. Increasing abdominal rigidity and a board-like feel upon palpationCevap
  4. D
    Arterial blood gas results showing a pHpH of 7.38, PaCO2PaCO_2 of 42 mm Hg, and HCO3−HCO_3^- of 24 mEq/L
  5. E
    Severe, continuous mid-epigastric pain that radiates to the client's back
  6. F
    The client independently assumes a side-lying position with knees drawn to the chest

Cevap

The findings requiring immediate intervention are carpal spasm during blood pressure measurement, new-onset fine crackles in the lung bases, and increasing abdominal rigidity.
The correct answers identify life-threatening complications associated with acute pancreatitis and its treatment. Carpal spasm (Trousseau's sign) indicates severe hypocalcemia caused by retroperitoneal fat necrosis. New-onset crackles suggest fluid volume overload from aggressive fluid resuscitation or the development of Acute Respiratory Distress Syndrome (ARDS). A rigid, board-like abdomen is a classic sign of peritonitis, which can result from pancreatic rupture or severe internal hemorrhage.

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1
Analyze the client's current diagnosis and treatment plan.
The client has acute pancreatitis and is receiving large volumes of intravenous fluids for resuscitation.
Understanding the pathophysiology and treatments helps identify potential systemic complications.
2
Evaluate each assessment finding to differentiate between expected disease manifestations and unstable complications.
Epigastric pain radiating to the back and assuming a fetal position are expected findings. The ABG values are normal.
Risk reduction requires prioritizing unexpected, life-threatening physiological changes over expected symptoms.
3
Identify the critical indicators of physiological deterioration.
Trousseau's sign (carpal spasm) indicates severe hypocalcemia. Crackles indicate fluid overload or ARDS. A board-like abdomen indicates peritonitis.
These three findings represent acute, potentially fatal complications that demand immediate medical intervention.

Anahtar Kavram

Reduction of Risk Potential in Acute Pancreatitis
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Konular

Reduction of Risk Potential

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