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.)
Initiate insulin drip.
Monitor blood glucose levels.
Continue regular diet as tolerated.
Maintain NPO status until pain-free.
Manage acute pain.
Correct Answer : B,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
Apply an ice pack directly to the affected area. This statement is incorrect. Applying ice to a snake bite can cause more harm than good. Ice can restrict blood flow and potentially increase tissue damage. The recommended approach is to keep the bite area still and at or below heart level to slow the spread of venom.
Choice B Reason
Immobilize the affected extremity with a splint. This is the correct intervention. Immobilizing the affected limb helps to slow the spread of venom by reducing movement. Keeping the limb still and using a splint can prevent the venom from circulating more rapidly through the body.
Choice C Reason
Place a tourniquet above and below the affected area. This statement is incorrect. Using a tourniquet is not recommended for snake bites as it can cause severe damage to the affected limb by cutting off blood flow completely. This can lead to tissue death and other complications.
Choice D Reason
Elevate the affected extremity. This statement is incorrect. Elevating the limb can increase the spread of venom. The affected limb should be kept at or below heart level to slow the venom’s spread.
Correct Answer is D
Explanation
Choice A Reason
“It is okay to not want to touch the burned areas of your body.” This statement is empathetic and acknowledges the client’s feelings, but it does not provide a constructive way to address their concerns about altered appearance. While it is important to validate the client’s feelings, offering a solution or support mechanism is more beneficial.
Choice B Reason
“Cosmetic surgery should be performed within the next year to be effective.” This statement is misleading. While timely intervention can be important, the timing of reconstructive or cosmetic surgery depends on various factors, including the extent of the burns, the healing process, and the patient’s overall health. It is not accurate to generalize that surgery must be performed within a year.
Choice C Reason
“Reconstructive surgery can completely restore your previous appearance.” This statement is incorrect and can give false hope. Reconstructive surgery aims to improve function and appearance, but it cannot completely restore the previous appearance. Managing expectations is crucial in the recovery process.
Choice D Reason
“It could be helpful for you to attend a support group for people who have burn injuries.” This statement is correct. Support groups provide emotional and psychological support, helping burn survivors cope with changes in appearance and other challenges. They offer a sense of community and shared experiences, which can be very beneficial for recovery.
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