# Situation: A 48-year-old man weighing 72 kg is admitted to the medical ward with mild acute pancreatitis related to heavy alcohol use. He has no organ failure. He is receiving lactated Ringer's solution intravenously (IV) and IV morphine for pain. On day 2, which finding should the nurse report to the physician at once?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630396  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 48-year-old man weighing 72 kg is admitted to the medical ward with mild acute pancreatitis related to heavy alcohol use. He has no organ failure. He is receiving lactated Ringer's solution intravenously (IV) and IV morphine for pain.

On day 2, which finding should the nurse report to the physician at once?

## 보기

1. Pain that eases when he sits up and leans forward in bed
2. Serum lipase of 980 U/L (normal 13–60 U/L)
3. Capillary glucose of 162 mg/dL (9.0 mmol/L)
4. Hand spasm while a blood pressure cuff is inflated **✔ 정답**

**정답: 4**

## 해설

Carpal spasm during blood pressure cuff inflation is a positive Trousseau sign, indicating hypocalcemia, which occurs in pancreatitis when calcium binds to areas of fat necrosis and can progress to tetany, seizures, and dysrhythmias. A high lipase supports the diagnosis but does not reflect severity, relief when leaning forward is typical, and mild hyperglycemia is monitored and treated per protocol.

## 심화 해설

The finding to report at once
He has mild acute pancreatitis. On day 2, his hand goes into spasm while a blood pressure cuff is inflated. Carpal spasm during cuff inflation is a positive Trousseau sign, which indicates hypocalcemia. Hypocalcemia can progress to tetany, seizures, laryngospasm, and dysrhythmias, so this is the finding the nurse reports at once.

Why pancreatitis lowers calcium
In acute pancreatitis, pancreatic enzymes leak into surrounding tissue and digest fat. The free fatty acids released by fat necrosis bind calcium, forming calcium soaps and lowering serum calcium. Low albumin and changes in parathyroid hormone response may contribute. Low ionized calcium increases the excitability of nerves and muscles, which is why compressing the arm with a cuff provokes carpal spasm. The related Chvostek sign is twitching of the facial muscles when the facial nerve is tapped in front of the ear.

Why the other findings are not urgent
Pain that eases when sitting up and leaning forward is typical of pancreatitis, because this position reduces pressure on the retroperitoneal pancreas. A lipase of 980 U/L is well above three times the upper limit, which supports the diagnosis, but the lipase level does not reflect severity and does not need urgent reporting on its own. A capillary glucose of 162 mg/dL (9.0 mmol/L) reflects mild stress hyperglycemia and reduced insulin release, which are common in pancreatitis and are monitored and treated per protocol.

| Finding | Meaning | Priority |
| --- | --- | --- |
| Pain eases leaning forward | Typical of pancreatitis | Expected |
| Lipase 980 U/L | Supports diagnosis; not a severity marker | Expected |
| Glucose 162 mg/dL (9.0 mmol/L) | Mild hyperglycemia | Monitor per protocol |
| Hand spasm with cuff | Positive Trousseau sign: hypocalcemia | Report at once |

Nursing actions
The nurse reports the sign, anticipates a serum calcium level and IV calcium replacement if ordered, places the client on cardiac monitoring when indicated, institutes seizure precautions, and keeps emergency airway equipment available because of the risk of laryngospasm.

Exam takeaway
Key point In pancreatitis, a positive Trousseau or Chvostek sign signals hypocalcemia and takes priority over expected findings such as a high lipase or typical positional pain.

## 임상 시나리오

Hypocalcemia in Acute PancreatitisRecognizing a positive Trousseau sign
In pancreatitis, fat necrosis releases fatty acids that bind calcium, lowering serum calcium. Carpal spasm during blood pressure cuff inflation is a positive Trousseau sign.

Hypocalcemia can progress to tetany, seizures, and dysrhythmias, so this finding is reported at once. A high lipase supports the diagnosis but does not reflect severity.

CautionPrepare for serum calcium testing, IV calcium if ordered, cardiac monitoring, and seizure precautions. Keep airway equipment nearby because of laryngospasm risk.

## 핵심 개념

- **Trousseau sign** — Carpal spasm provoked by inflating a blood pressure cuff above systolic pressure, indicating hypocalcemia.
- **Chvostek sign** — Twitching of facial muscles when the facial nerve is tapped, indicating hypocalcemia.
- **Fat necrosis** — Destruction of fat tissue by pancreatic enzymes, releasing fatty acids that bind calcium.
- **Tetany** — Involuntary muscle spasms caused by increased neuromuscular excitability, often from hypocalcemia.

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