A nurse is caring for a patient who is being treated for acute pain from an episode of pancreatitis. The nurse has identified a nursing diagnosis of Ineffective Breathing Pattern related to pain secondary to effects of surgery. Which intervention should the nurse perform in order to best address this diagnosis?
Position the client supine to facilitate diaphragm movement.
Administer corticosteroids by nebulizer as prescribed.
Perform oral suctioning as needed to remove secretions.
Administer analgesic per orders.
The Correct Answer is D
A. Supine positioning can impair diaphragm movement and worsen breathing; semi-Fowler’s is preferred.
B. Corticosteroids are not typically indicated for this condition.
C. Suctioning may be necessary for secretion management but does not directly address pain-related breathing issues.
D. Administering analgesics reduces pain, allowing improved chest expansion and effective breathing, directly addressing the ineffective breathing pattern caused by pain.
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Related Questions
Correct Answer is C
Explanation
A. While treatment decisions may be necessary, they are typically made with medical guidance and are not usually the primary psychosocial concern.
B. Spiritual distress can occur but is less commonly reported than body image issues in younger clients with visible physical changes.
C. Disturbed body image is a key psychosocial concern in Cushing syndrome, especially in young adults, due to physical changes like moon face, truncal obesity, and skin alterations that can significantly affect self-esteem.
D. Feelings of powerlessness may arise but are generally secondary to the distress caused by altered appearance and self-perception.
Correct Answer is A
Explanation
A. Gallstones are one of the most common causes of acute pancreatitis. They can obstruct the pancreatic duct, leading to inflammation and enzyme activation within the pancreas.
B. Hypolipidemia is not associated with pancreatitis; in fact, hyperlipidemia is a known risk factor.
C. COPD is unrelated to pancreatic inflammation and is not a typical risk factor.
D. Diabetes mellitus is more often a complication of chronic pancreatitis, not a primary cause of acute pancreatitis.
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