A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea.
After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?
Reinforce bed rest until analgesic is effective.
Place bed in reverse Trendelenburg position.
Raise head of bed until at a 90-degree angle.
Position bedside table for client to lean across.
The Correct Answer is D
A. Reinforcing bed rest until the analgesic is effective may not address the client's need to sit up and lean forward. It's important to respond to the client's discomfort and find a position that
provides relief.
B. Placing the bed in reverse Trendelenburg position (head elevated, feet lowered) may not be the most effective position for a client experiencing severe epigastric pain and nausea. This
position could potentially worsen symptoms or discomfort.
C. Raising the head of the bed to a 90-degree angle may not provide optimal relief for the client.
While it's essential to elevate the head of the bed for comfort and to prevent aspiration, it may not address the client's specific need to lean forward.
D. Positioning a bedside table for the client to lean across allows the client to assume a position that often provides relief for epigastric pain associated with pancreatitis. Leaning forward can
help reduce pressure on the pancreas and alleviate discomfort. This position also facilitates drainage of gastric contents and may help alleviate nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Monitor and document strict intake and output: While monitoring intake and output is
important in managing fluid balance, it may not directly address the potential complications associated with hyperkalemia and hyperglycemia.
B. Assess the serum potassium level every 4 hours: While monitoring potassium levels is important, obtaining a 12-lead electrocardiogram provides immediate information about the cardiac effects of hyperkalemia, which can be life-threatening.
C. Obtain a 12-lead electrocardiogram daily: Hyperkalemia can lead to serious cardiac arrhythmias, including bradycardia, heart block, and ventricular fibrillation. Daily
electrocardiograms can help detect these changes early.
D. Evaluate glucose levels before and after meals: While monitoring glucose levels is important, the immediate concern in this scenario is the potential cardiac effects of hyperkalemia.
Correct Answer is B
Explanation
A. Instituting an exercise plan is important for overall health and may be part of the client's
treatment plan. However, the primary focus initially should be on addressing disordered eating behaviors and achieving a balanced diet.
B. Regulating food portions is a crucial goal for individuals with binge eating disorder to help establish healthier eating habits and prevent episodes of overeating.
C. Obtaining satisfaction with appearance may be a long-term goal for some individuals with binge eating disorder, but it is not typically the first goal addressed in treatment.
D. Achieving a steady weight loss may not be appropriate for all individuals with binge eating disorder, as the focus should be on promoting a healthy relationship with food rather than solely on weight loss.
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