A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?

Withhold oral fluids and food.

Auscultate the client’s lungs.

Provide oral hygiene.

Assist the client to a side-lying position.

Answer and Explanation

The Correct Answer is A

Choice A reason: Withhold oral fluids and food

Withholding oral fluids and food (NPO status) is a critical intervention for clients with acute pancreatitis. This helps to rest the pancreas by reducing the stimulation of pancreatic enzyme secretion, which can exacerbate inflammation and pain. Maintaining NPO status is essential to prevent further pancreatic damage and to allow the pancreas to heal.

Choice B reason: Auscultate the client’s lungs

While auscultating the lungs is an important part of the overall assessment, it is not the immediate priority after pain management in acute pancreatitis. Respiratory complications can occur, but the primary focus should be on managing the pancreatic inflammation and preventing further damage.

Choice C reason: Provide oral hygiene

Providing oral hygiene is important for overall patient care, especially when the client is NPO. However, it is not the priority intervention immediately after pain management. The primary concern is to prevent further pancreatic stimulation and manage the inflammation.

Choice D reason: Assist the client to a side-lying position

Assisting the client to a side-lying position can help with comfort and may be beneficial in managing pain. However, it is not the priority intervention. The main focus should be on preventing further pancreatic stimulation by withholding oral intake.

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Correct Answer is A

Explanation

Choice A reason: A private room in a quiet location on the unit is the best option for a client in the manic phase of bipolar disorder. This environment minimizes stimulation and distractions, which can help reduce agitation and hyperactivity. It also allows for better control of the client’s environment, which is crucial for managing manic symptoms.

Choice B reason: A private room across from the exercise room is not ideal because the proximity to the exercise room can increase stimulation and noise, potentially exacerbating manic symptoms. Clients in the manic phase need a calm and quiet environment to help stabilize their mood.

Choice C reason: A semi-private room across from the day room is also not suitable. The day room is typically a busy area with a lot of activity and noise, which can be overstimulating for a client in the manic phase. Sharing a room with another client can further increase the risk of agitation and conflict.

Choice D reason: A semi-private room across from the snack area is not recommended for similar reasons. The snack area is likely to have frequent traffic and noise, which can be disruptive. Additionally, sharing a room can lead to increased stimulation and potential conflicts with a roommate.

A. Have you had a recent influenza infection? B. Have you traveled overseas recently? C. Do you have a history of chronic alcohol abuse? D. Are you taking a multivitamin?

Correct Answer is A

Explanation

Choice A reason: Have you had a recent influenza infection?

Guillain-Barré syndrome (GBS) is often preceded by an infection, most commonly respiratory or gastrointestinal infections. Influenza is a significant respiratory infection that can trigger GBS. Asking about recent influenza infection helps in identifying a potential cause of the syndrome. According to the Mayo Clinic, many cases of GBS occur after a respiratory or gastrointestinal infection1. Therefore, this question is crucial in the assessment of a client with suspected GBS.

Choice B reason: Have you traveled overseas recently?

While travel history can be relevant in diagnosing various conditions, it is less directly related to Guillain-Barré syndrome. GBS is not typically associated with travel but rather with infections that can occur anywhere. Therefore, this question is less pertinent compared to asking about recent infections.

Choice C reason: Do you have a history of chronic alcohol abuse?

Chronic alcohol abuse can lead to various neurological conditions, but it is not specifically linked to Guillain-Barré syndrome. GBS is an acute condition often triggered by an infection, not by chronic alcohol use. Thus, while this question might be relevant in a broader neurological assessment, it is not directly related to GBS.

Choice D reason: Are you taking a multivitamin?

The use of multivitamins is generally not related to the development of Guillain-Barré syndrome. This question does not help in identifying the cause or confirming the diagnosis of GBS. It is more relevant to a general health assessment rather than a specific inquiry for GBS.

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A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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