A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in this patient's plan of care to reduce discomfort?
Maintain nothing by mouth (NPO) and administer intravenous fluids.
Provide small, frequent feedings with no concentrated sweets.
Administer morphine sulfate intramuscularly every 4 hours as needed.
Position the patient in a flat, supine position to decrease discomfort.
The Correct Answer is A
Choice A reason: Maintaining nothing by mouth (NPO) and administering intravenous fluids is the best intervention to reduce discomfort in a patient with acute pancreatitis. NPO status helps to rest the pancreas by preventing the secretion of pancreatic enzymes that can exacerbate inflammation and pain. Intravenous fluids are essential to maintain hydration and electrolyte balance while the patient is not eating or drinking.
Choice B reason: Providing small, frequent feedings with no concentrated sweets is not appropriate for a patient with acute pancreatitis. The priority is to keep the patient NPO to rest the pancreas. Introducing any food can stimulate the pancreas and worsen the condition.
Choice C reason: Administering morphine sulfate intramuscularly every 4 hours as needed can help manage pain, but the preferred route for pain medication in acute pancreatitis is intravenous, as it provides quicker relief and avoids the discomfort of intramuscular injections. Pain management is important, but it should be part of a broader plan that includes NPO status and IV fluids.
Choice D reason: Positioning the patient in a flat, supine position is not recommended for reducing discomfort in acute pancreatitis. Patients often find relief in a semi-Fowler's position (head elevated) or by leaning forward, which can help reduce abdominal pain and pressure on the inflamed pancreas.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Vasopressin (Desmopressin) is not primarily used to decrease blood pressure. It is an antidiuretic hormone that helps manage diabetes insipidus by reducing urine output. While vasopressin can have vasoconstrictive effects, its primary role in this context is to control urine production, not blood pressure.
Choice B reason: The primary therapeutic outcome of vasopressin (Desmopressin) in a patient with diabetes insipidus is to decrease urine output. Diabetes insipidus leads to excessive urine production and dehydration. Vasopressin acts on the kidneys to increase water reabsorption, thereby reducing urine volume and helping to maintain fluid balance.
Choice C reason: Level of consciousness is not a direct therapeutic outcome of vasopressin (Desmopressin). While managing fluid balance can indirectly affect a patient's overall condition and well-being, vasopressin specifically targets the kidneys to reduce urine output and does not have a direct impact on consciousness levels.
Choice D reason: Specific gravity refers to the concentration of solutes in the urine. While vasopressin can affect the specific gravity by concentrating the urine and reducing volume, the primary therapeutic goal is to manage urine output in patients with diabetes insipidus. The focus is on reducing the excessive urine production rather than altering specific gravity.
Correct Answer is C
Explanation
Choice A reason: Rechecking all of the patient's vital signs is a good practice, but it is not the priority action in this scenario. The patient's symptoms indicate a potential case of autonomic dysreflexia, a life-threatening condition that requires immediate action to reduce blood pressure and address the cause. Rechecking vital signs alone will not resolve the underlying issue.
Choice B reason: Elevating the patient's knees and lowering the head of the bed is not an appropriate action in this situation. This position could potentially increase intracranial pressure and exacerbate the patient's condition. The focus should be on measures that will help lower the blood pressure and alleviate the symptoms of autonomic dysreflexia.
Choice C reason: The priority action is to elevate the head of the bed immediately and notify the provider. Elevating the head of the bed helps to decrease blood pressure and improve venous return. Promptly notifying the provider ensures that the patient receives timely medical intervention to address the underlying cause of autonomic dysreflexia, which is critical for preventing further complications.
Choice D reason: Administering PRN Tylenol for the patient's headache is not the priority in this situation. While pain management is important, the patient's symptoms suggest a more severe condition (autonomic dysreflexia) that requires immediate attention to lower blood pressure and address the root cause. Pain medication alone will not resolve the underlying issue and could delay necessary interventions.
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