A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

Correct Answer: B

Rationale: The correct answer is B: Severe abdominal pain that is unrelieved by vomiting. In acute pancreatitis, the pancreatic enzymes cause inflammation and damage to the pancreas, leading to severe abdominal pain that is typically constant and not relieved by vomiting. Vomiting may even worsen the pain. Other choices are incorrect because severe abdominal pain in acute pancreatitis is not relieved by vomiting (A), hypothermia is not a hallmark sign of acute pancreatitis (C), and epigastric pain radiating to the neck area is not a specific hallmark sign (D).

Correct Answer: D

Rationale: Rationale for Correct Answer (D): The patient should avoid drugs and alcohol to prevent further damage to the liver affected by hepatitis B. Substance abuse can exacerbate liver disease. This statement indicates understanding of the importance of liver health. Summary of Other Choices: A: This statement is correct because individuals with hepatitis B should not donate blood to prevent transmission. B: This statement is correct because unprotected sex can transmit hepatitis B to sexual partners. C: This statement is correct because sharing needles can spread hepatitis B through blood-to-blood contact.

Correct Answer: C

Rationale: The correct answer is C: Teaching the client to use a folded blanket or pillow to splint the incision. This measure helps support the incision site, reducing pain during coughing and deep breathing. Splinting the incision promotes effective coughing and deep breathing post-surgery, aiding in lung expansion and preventing complications like atelectasis. Explanation of why other choices are incorrect: A: Having the client take rapid, shallow breaths to decrease pain is incorrect as it can lead to inadequate lung expansion and retention of secretions. B: Having the client lay on the left side while coughing and deep breathing is incorrect as it does not directly support the incision site and may not be as effective in reducing pain. D: Withholding pain medication so the client can be alert enough to follow the nurse's instructions is incorrect as pain management is crucial post-surgery for comfort and optimal recovery.

Correct Answer: B

Rationale: The correct answer is B because discussing concerns about sexual functioning is an appropriate expected outcome at this point. After an abdominal perineal resection with a colostomy, it is important for the client to address any concerns related to sexual functioning as it can impact their quality of life. A: The client maintaining a high-fiber diet is not the most appropriate expected outcome at this point as it may be too soon after surgery to focus solely on dietary adjustments. C: The client maintaining bedrest is not appropriate as early mobilization is usually encouraged after surgery to prevent complications. D: Limiting fluid intake to 1000 ml/day is not recommended as adequate hydration is crucial for recovery post-surgery.

Correct Answer: D

Rationale: Rationale for Correct Answer (D): By assessing for gastric residual before administering another feeding through the nasogastric tube, the nurse can evaluate absorption of the last feeding. If there is a significant amount of residual, it may indicate poor absorption, which could lead to complications such as aspiration. This assessment helps in determining the appropriate timing and amount of the next feeding to prevent complications. Summary of Incorrect Choices: A: Confirming proper nasogastric tube placement is typically done using other methods like pH testing or X-ray. This assessment does not directly relate to evaluating absorption. B: Observing gastric contents may provide information about the patient's gastric secretions but does not specifically help in evaluating the absorption of the last feeding. C: Assessing fluid and electrolyte status is important but not the primary purpose of checking gastric residual before administering a feeding. This assessment is more focused on monitoring the patient's overall hydration and electrolyte balance.