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.

Answer and Explanation

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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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. Regulation of water balance B. Regulation of acid-base balance C. Regulation of blood pressure D. Regulation of metabolic wastes

Correct Answer is A

Explanation

Choice A reason: The regulation of water balance by the kidneys involves maintaining the appropriate volume and concentration of body fluids. By taking daily weights, nurses can assess fluid retention or loss, while monitoring intake and output (I&O) helps track fluid balance. Specific gravity measures the concentration of urine, which provides information about the kidneys' ability to concentrate or dilute urine. These interventions directly relate to the kidneys' role in regulating water balance.

Choice B reason: Regulation of acid-base balance by the kidneys involves maintaining the proper pH levels in the blood through excretion or retention of hydrogen ions and bicarbonate. While important, this function is not the primary focus of interventions like daily weights, I&O, and specific gravity monitoring, which are more related to water balance.

Choice C reason: The regulation of blood pressure by the kidneys is achieved through the renin-angiotensin-aldosterone system, which controls blood volume and systemic vascular resistance. Although fluid balance can indirectly affect blood pressure, the specific interventions mentioned are more directly related to water balance than blood pressure regulation.

Choice D reason: Regulation of metabolic wastes involves the kidneys filtering and excreting waste products from the blood. This function is vital for overall health, but interventions like daily weights, I&O, and specific gravity monitoring are more focused on assessing fluid balance rather than directly measuring waste elimination.

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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?

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Naxlex Comprehensive Predictor Exams

What findings would the nurse expect when caring for a client who is experiencing spinal shock?

Correct Answer is D

Explanation

Nursing interventions such as taking daily weights, I&O, and monitoring specific gravity relate to which kidney function?

Correct Answer is A

Explanation

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