A patient with ankylosing spondylitis is admitted with severe back pain and restricted mobility. What nursing intervention should be prioritized to enhance respiratory function and prevent complications?
Recommending complete bed rest
Encouraging deep breathing exercises regularly
Administering non-steroidal anti-inflammatory drugs (NSAIDS)
Applying heat packs to the lower back
The Correct Answer is B
Rationale:
A. Recommending complete bed rest is contraindicated in patients with ankylosing spondylitis. Prolonged immobility can worsen spinal stiffness, postural deformities, and chest wall restriction, increasing the risk of respiratory complications such as atelectasis and pneumonia. Maintaining mobility is essential to preserve lung expansion and functional ability.
B. Encouraging deep breathing exercises regularly is the priority nursing intervention to enhance respiratory function. Ankylosing spondylitis can cause fusion of the costovertebral joints, leading to decreased chest wall expansion and reduced lung capacity. Deep breathing exercises promote maximal lung expansion, improve oxygenation, and help prevent complications such as atelectasis and respiratory infections.
C. NSAIDs are a cornerstone of treatment for pain and inflammation in ankylosing spondylitis, but they do not directly address respiratory function. While important for symptom control, medication administration is a secondary priority compared to interventions that prevent potentially serious respiratory complications.
D. Applying heat packs to the lower back may help relieve muscle tension and pain, but it does not improve chest expansion or lung function. Heat therapy is a comfort measure and should not take precedence over interventions aimed at preserving respiratory capacity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Nutritional deficiency can develop with a small bowel obstruction if it persists for a prolonged period, but it is not the immediate life-threatening concern. Early in the course, other complications take priority.
B. Perforation of the bowel is the most serious and urgent complication of small bowel obstruction. Increased intraluminal pressure from accumulated gas and fluid can weaken the intestinal wall, leading to perforation, peritonitis, sepsis, and potentially death. Assessing for rigid abdomen, severe worsening pain, fever, and signs of peritoneal irritation is critical. This is a surgical emergency, and prompt recognition and intervention are essential.
C. Dehydration due to vomiting and fluid shifts is a common complication, but it is secondary to the acute risk of perforation. Fluid resuscitation is important but comes after prioritizing identification and management of life-threatening conditions.
D. Electrolyte imbalance (e.g., hypokalemia, hyponatremia) can result from vomiting and nasogastric suctioning, but like dehydration, it is not immediately life-threatening compared to perforation. It should be corrected as part of ongoing management.
Correct Answer is C
Explanation
Rationale:
A. Providing analgesics is important for pain management, but it is not the highest priority when appendicitis is suspected. Uncontrolled pain can indicate worsening inflammation or rupture, so assessment and monitoring take precedence before administering strong analgesics.
B. Performing gentle palpation can help assess tenderness, but deep or aggressive palpation can increase the risk of rupturing an inflamed appendix. Assessment should be cautious, prioritizing observation and minimal manipulation.
C. Avoiding deep palpation and monitoring for signs of rupture is the priority action. Appendicitis can progress to perforation, which may lead to peritonitis, sepsis, and shock. Careful monitoring for sudden worsening pain, rebound tenderness, rigidity, fever, or changes in vital signs helps prevent complications and ensures timely surgical intervention.
D. Administering IV fluids is necessary to maintain hydration, especially if the patient is NPO in preparation for surgery. However, it is secondary to the priority of preventing rupture and monitoring for acute changes that indicate an emergent situation.
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