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 J
Explanation
Choice A reason: Carbon monoxide poisoning occurs when carbon monoxide binds to hemoglobin, preventing oxygen from binding and leading to hypoxia. Symptoms include headache, dizziness, weakness, upset stomach, vomiting, chest pain, and confusion. However, a hoarse voice and a brassy cough are not typical symptoms of carbon monoxide poisoning. These symptoms are more indicative of an inhalation injury due to direct thermal or chemical damage to the airway.
Choice B reason: Pulmonary edema refers to fluid accumulation in the lungs, which can cause difficulty breathing, a feeling of suffocating or drowning, and a cough that produces frothy sputum. Although pulmonary edema can occur after significant burn injuries due to fluid resuscitation or other complications, the specific symptoms of a hoarse voice and brassy cough are more suggestive of an inhalation injury than pulmonary edema.
Choice C reason: An inhalation injury is
The correct answer. This type of injury occurs when a patient inhales smoke, hot gases, or toxic chemicals during a fire. Symptoms can include a hoarse voice, brassy cough, stridor, and respiratory distress. The hoarseness and brassy cough are classic signs of damage to the upper airway due to the inhalation of hot gases or smoke, leading to swelling and irritation of the airway tissues.
Choice D reason: Bacterial pneumonia is an infection of the lungs that can cause symptoms such as fever, chills, cough with phlegm, shortness of breath, and chest pain. While pneumonia can develop as a secondary complication in burn patients, the immediate symptoms of a hoarse voice and brassy cough are more indicative of an inhalation injury rather than bacterial pneumonia.
Correct Answer is A
Explanation
Choice A reason: Explaining that diarrhea is expected and that it is how the body gets rid of ammonia is accurate. Lactulose is often prescribed for patients with hepatic encephalopathy, and its purpose is to reduce blood ammonia levels by promoting bowel movements. Diarrhea is a common and anticipated side effect, as it helps eliminate ammonia from the body.
Choice B reason: Recommending Kaopectate for loose stools is not appropriate in this context. Kaopectate is an anti-diarrheal medication, and using it would counteract the effect of lactulose, which aims to promote bowel movements to reduce ammonia levels.
Choice C reason: Instructing the patient to stop taking the medication until stools firm up is incorrect. Lactulose should be continued as prescribed to maintain its therapeutic effect of reducing blood ammonia levels. Stopping the medication would negate its benefits and potentially worsen the patient's condition.
Choice D reason: Suggesting to send a stool specimen to the laboratory is unnecessary in this scenario. Diarrhea is an expected side effect of lactulose, and there is no indication that a stool specimen needs to be analyzed unless there are signs of infection or other complications.
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