When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

Place the client in a side-lying position.

Administer hydromorphone for pain as prescribed.

Obtain daily weights.

Maintain a high-calorie, high-protein diet.

Monitor the client's respiratory status.

Answer and Explanation

Correct Answer : A,B,E

Choice A reason: Placing the client in a side-lying position is beneficial for comfort and can help alleviate pain in clients with acute pancreatitis. This position can reduce pressure on the pancreas and improve circulation, helping to manage pain and discomfort effectively.

Choice B reason: Administering hydromorphone for pain as prescribed is essential in managing acute abdominal pain associated with acute pancreatitis. Pain control is a priority in the care of these clients because unmanaged pain can lead to increased stress and further complications. Hydromorphone, a potent opioid analgesic, helps to effectively manage severe pain.

Choice C reason: Obtaining daily weights is important for monitoring a client's nutritional status and fluid balance, but it is not directly related to the immediate management of acute abdominal pain in acute pancreatitis. While it is a relevant intervention, it is not as critical as the other measures listed.

Choice D reason: Maintaining a high-calorie, high-protein diet is not appropriate for a client with acute pancreatitis. In fact, clients with acute pancreatitis are often placed on a nil-per-os (NPO) status initially to rest the pancreas and reduce enzyme secretion. Once the inflammation subsides, a low-fat, bland diet may be introduced gradually.

Choice E reason: Monitoring the client's respiratory status is crucial because clients with acute pancreatitis are at risk for respiratory complications, such as pleural effusion, acute respiratory distress syndrome (ARDS), or atelectasis. Close monitoring ensures early detection and intervention for any respiratory issues that may arise.

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Correct Answer is D

Explanation

Choice A reason: Hypotension and a decreased level of consciousness can occur in spinal shock due to the disruption of the sympathetic nervous system, but these are not the hallmark features. They are more secondary effects rather than the primary presentation.

Choice B reason: Stridor, garbled speech, or inability to clear the airway are not typical findings in spinal shock. These symptoms are more indicative of airway obstruction or respiratory distress, which are not directly related to spinal shock.

Choice C reason: Bradycardia and decreased urinary output can occur in spinal shock due to the loss of sympathetic tone, leading to unopposed parasympathetic activity. While these are relevant symptoms, they do not encompass the full scope of spinal shock.

Choice D reason: The primary findings in spinal shock are the temporary loss of motor, sensory, reflex, and autonomic function below the level of the spinal injury. This includes flaccid paralysis, loss of reflexes, and autonomic dysfunction, such as hypotension and bradycardia. These symptoms are the most defining characteristics of spinal shock.

A. pH 7.50, pO2 85, pCO2 35, HCO3 30 mEq/L B. pH 7.30, pO2 90, pCO2 35, HCO3 20 mEq/L C. pH 7.50, pO2 95, pCO2 25, HCO3 22 mEq/L D. pH 7.30, pO2 80, pCO2 55, HCO3 22 mEq/L

Correct Answer is D

Explanation

Choice A reason: The values pH 7.50, pO2 85, pCO2 35, HCO3 30 mEq/L indicate alkalosis with a high bicarbonate level, which is not consistent with the patient’s slow respiratory rate that would typically lead to respiratory acidosis.

Choice B reason: The values pH 7.30, pO2 90, pCO2 35, HCO3 20 mEq/L indicate metabolic acidosis with normal pCO2, which does not align with the respiratory issue described (hypoventilation).

Choice C reason: The values pH 7.50, pO2 95, pCO2 25, HCO3 22 mEq/L indicate respiratory alkalosis, which is characterized by a low pCO2. This is not consistent with the patient’s hypoventilation, which would lead to elevated pCO2 levels.

Choice D reason: The values pH 7.30, pO2 80, pCO2 55, HCO3 22 mEq/L indicate respiratory acidosis, which aligns with the patient’s hypoventilation due to anesthesia effects and incisional pain. The elevated pCO2 and decreased pH are consistent with reduced respiratory rate and shallow breathing.

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When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Explanation

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