A nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?

The client reports relief from pain when lying in the prone position.

The client reports that their low-back pain radiates upward toward one scapula.

The client reports tingling and a burning sensation in one foot.

The client reports decreased pain when the affected leg is raised.

Answer and Explanation

The Correct Answer is C

Choice A Reason

The client reports relief from pain when lying in the prone position. This statement is incorrect. Clients with a herniated lumbar disc typically find relief from pain when lying on their back with their knees bent or in a fetal position. Lying prone can sometimes exacerbate the pain.

Choice B Reason

The client reports that their low-back pain radiates upward toward one scapula. This statement is incorrect. Pain from a herniated lumbar disc usually radiates downward into the buttocks, legs, and sometimes the feet, not upward toward the scapula.

Choice C Reason

The client reports tingling and a burning sensation in one foot. This is the correct finding. A herniated lumbar disc can compress spinal nerves, leading to symptoms such as tingling, numbness, and a burning sensation in the legs and feet.

Choice D Reason

The client reports decreased pain when the affected leg is raised. This statement is incorrect. Raising the affected leg often increases pain due to the stretching of the sciatic nerve, which can be compressed by the herniated disc.

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Correct Answer is ["B","E"]

Explanation

Choice A Reason:

Initiating an insulin drip is not a standard intervention for all clients with acute pancreatitis. This intervention is typically reserved for clients who develop hyperglycemia or diabetes as a complication of pancreatitis. Acute pancreatitis can affect the pancreas’ ability to produce insulin, but not all clients will require an insulin drip.

Choice B Reason:

Monitoring blood glucose levels is crucial for clients with acute pancreatitis because the pancreas plays a key role in regulating blood sugar. Inflammation or damage to the pancreas can lead to fluctuations in blood glucose levels, making regular monitoring essential to manage potential hyperglycemia or hypoglycemia.

Choice C Reason:

Continuing a regular diet as tolerated is not appropriate for clients with acute pancreatitis. These clients are typically kept NPO (nothing by mouth) to rest the pancreas and reduce the secretion of pancreatic enzymes, which can exacerbate inflammation and pain.

Choice D Reason:

Maintaining NPO status until the client is pain-free is a standard intervention for acute pancreatitis. This approach helps to rest the pancreas and prevent the release of digestive enzymes that can further inflame the pancreas. Once the client is pain-free and inflammation has subsided, a gradual reintroduction of oral intake can be considered.

Choice E Reason:

Managing acute pain is a critical aspect of care for clients with acute pancreatitis. Pain management can include medications such as opioids, as well as non-pharmacological interventions like positioning and relaxation techniques. Effective pain management improves the client’s comfort and can help reduce stress on the pancreas.

A. Initiate insulin drip. B. Monitor blood glucose levels. C. Continue regular diet as tolerated. D. Maintain NPO status until pain-free. E. Manage acute pain.

Correct Answer is ["B","E"]

Explanation

Choice A Reason

Initiate insulin drip. This intervention is not typically included in the standard care plan for all patients with acute pancreatitis. Insulin drips are generally reserved for cases of hypertriglyceridemia-induced pancreatitis, where insulin helps to lower triglyceride levels. For most patients with acute pancreatitis, this is not a standard intervention.

Choice B Reason

Monitor blood glucose levels. This is a correct intervention. Acute pancreatitis can affect the pancreas’ ability to regulate blood sugar, leading to hyperglycemia or hypoglycemia. Monitoring blood glucose levels helps in managing these potential complications and ensuring appropriate treatment.

Choice C Reason

Continue regular diet as tolerated. This statement is incorrect. Patients with acute pancreatitis are usually kept NPO (nothing by mouth) initially to rest the pancreas. Once the inflammation subsides, they may gradually reintroduce oral intake starting with clear liquids and progressing to a low-fat diet.

Choice D Reason

Maintain NPO status until pain-free. This is partially correct but not entirely accurate. While initial management often includes NPO status to rest the pancreas, current guidelines suggest that early enteral feeding can be beneficial and should be started as soon as tolerated. Prolonged NPO status is no longer the standard of care.

Choice E Reason

Manage acute pain. This is a correct intervention. Pain management is a critical component of care for patients with acute pancreatitis. Effective pain control improves patient comfort and can help reduce the stress response associated with severe pain.

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A nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

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