A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Encourage rest until the analgesic becomes effective.

Raise head of bed until at a 90 degree angle.

Place bed in a reverse Trendelenburg position.

Position bedside table so the client can lean across it.

Answer and Explanation

The Correct Answer is D

Choice A: Encourage rest until the analgesic becomes effective. This is not the best intervention, as it does not address the client's preference or comfort level. The analgesic may take some time to relieve the pain, and forcing the client to lie down may increase the pressure on the pancreas and worsen the pain.

Choice B: Raise head of bed until at a 90 degree angle. This is not the best intervention, as it does not address the client's preference or comfort level. Raising the head of bed may help reduce abdominal distension and improve breathing, but it may not relieve the pain as much as leaning forward.

Choice C: Place bed in a reverse Trendelenburg position. This is not the best intervention, as it does not address the client's preference or comfort level. Placing the bed in a reverse Trendelenburg position may help shift the abdominal organs away from the pancreas and reduce inflammation, but it may not relieve the pain as much as leaning forward.

Choice D: Position bedside table so the client can lean across it. This is the best intervention, as it addresses the client's preference and comfort level. Leaning forward may help decrease the tension on the pancreas and relieve the pain. The bedside table can provide support and stability for the client while sitting up.

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Correct Answer is A

Explanation

Choice A reason: This is correct because it addresses both the physical and emotional needs of the child and the mother. The nurse should provide comfort and reassurance to the mother and explain that occasional accidents are normal and not a sign of failure.

Choice B reason: This is incorrect because it implies that the mother is incompetent and needs external help. The nurse should first establish rapport and trust with the mother before suggesting any resources or interventions.

Choice C reason: This is incorrect because it suggests that there is something wrong with the child's kidneys, which may alarm and offend the mother. The nurse should not jump to conclusions without assessing the child's history and symptoms.

Choice D reason: This is incorrect because it generalizes and stereotypes boys as being slower than girls in toilet training. The nurse should not make assumptions based on gender and should respect individual differences.

A. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. B. An 18-year-old client with antisocial behavior who is being yelled at by other clients. C. A 16-year-old client diagnosed with major depression who refuses to participate in group. D. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.

Correct Answer is B

Explanation

Choice A: A 14-year-old client with anorexia nervosa refusing to eat the evening snack is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.

Choice B: An 18-year-old client with antisocial behavior being yelled at by other clients requires immediate attention. This situation can escalate quickly and may lead to physical harm or emotional distress for the client.

Choice C: A 16-year-old client diagnosed with major depression refusing to participate in group is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.

Choice D: A 17-year-old client diagnosed with bipolar disorder pacing around the lobby might be experiencing agitation or restlessness, but unless they’re showing signs of immediate distress or posing a risk to themselves or others, it’s not the most urgent situation.

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A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Nursing Test Bank

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