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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Intention tremors are not typically associated with Addison’s disease. Intention tremors are more commonly seen in conditions affecting the cerebellum, such as multiple sclerosis or cerebellar ataxia.
Choice B reason: Purple striations (striae) are more commonly associated with Cushing’s syndrome, which is characterized by excessive cortisol levels. Addison’s disease, on the other hand, involves insufficient cortisol production.
Choice C reason: Hirsutism refers to excessive hair growth in women in areas where hair is normally minimal or absent. This condition is more commonly associated with polycystic ovary syndrome (PCOS) or other endocrine disorders, not Addison’s disease.
Choice D reason: Hyperpigmentation is a hallmark sign of Addison’s disease. It occurs due to increased production of melanocyte-stimulating hormone (MSH) as a byproduct of elevated adrenocorticotropic hormone (ACTH) levels. This leads to darkening of the skin, especially in areas exposed to friction, such as the elbows, knees, knuckles, and scars.
Correct Answer is B
Explanation
Choice A reason:
Nursing assistants are at risk for various musculoskeletal injuries due to the physical nature of their work, which often involves lifting and moving patients. However, their risk for repetitive motion injuries is generally lower compared to occupations that involve repetitive tasks over extended periods.
Choice B reason:
Assembly line workers are highly susceptible to repetitive motion injuries. Their work typically involves performing the same motions repeatedly, which can lead to conditions such as carpal tunnel syndrome, tendonitis, and other musculoskeletal disorders. The repetitive nature of their tasks places significant strain on specific muscle groups and joints.
Choice C reason:
Truck drivers are more prone to injuries related to prolonged sitting and vibration exposure, such as lower back pain and sciatica. While they may perform some repetitive tasks, such as shifting gears, these do not typically constitute the primary risk for repetitive motion injuries.
Choice D reason:
Elementary school teachers are less likely to suffer from repetitive motion injuries compared to assembly line workers. Their job involves a variety of activities, including standing, walking, and interacting with students, which reduces the likelihood of repetitive strain on specific muscle groups.
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