In planning the care for a patient with acute pancreatitis, the nurse should make which of these goals the highest?
Effective pain management.
Decrease patient anxiety.
Adequate hydration achieved.
Decrease potassium intake.
The Correct Answer is A
Choice A reason: Effective pain management is the highest priority in the care of a patient with acute pancreatitis. Severe abdominal pain is a hallmark of acute pancreatitis and can significantly impact the patient's comfort and ability to participate in other aspects of their care. Managing pain effectively helps improve the patient's overall well-being and allows for better participation in treatments and recovery.
Choice B reason: Decreasing patient anxiety is important, but it is not the primary goal in the acute management of pancreatitis. Addressing anxiety can help improve the patient's experience and adherence to treatment, but managing pain and hydration are more critical in the immediate care.
Choice C reason: Adequate hydration is crucial in the management of acute pancreatitis, as dehydration can worsen the condition and lead to complications. However, pain management takes precedence because uncontrolled pain can lead to further stress and complications, hindering the effectiveness of hydration and other treatments.
Choice D reason: Decreasing potassium intake is not a primary goal in the management of acute pancreatitis. While electrolyte balance is important, there is no direct indication that potassium levels need to be specifically managed unless there is a documented imbalance. The focus should be on pain management and hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Monitoring amylase and lipase levels is the best way to determine the effectiveness of treatment in a patient with pancreatitis. These enzymes are produced by the pancreas, and their levels in the blood increase significantly during an episode of pancreatitis. As treatment progresses and the inflammation of the pancreas decreases, the levels of these enzymes should return to normal. Therefore, checking the levels of amylase and lipase is a direct indicator of the patient's response to treatment.
Choice B reason: Hematocrit and hemoglobin levels are important for assessing overall blood volume and oxygen-carrying capacity, but they are not specific indicators of pancreatitis treatment effectiveness. While these levels can provide information about the patient's general health and hydration status, they do not specifically reflect changes in pancreatic inflammation.
Choice C reason: Red blood cell count is another measure of the blood's oxygen-carrying capacity and overall health, but like hematocrit and hemoglobin, it is not specific to pancreatitis. Changes in red blood cell count can occur due to various factors, but they do not provide direct information about the effectiveness of pancreatitis treatment.
Choice D reason: Serum uric acid levels are typically monitored in conditions such as gout or kidney stones, and they are not related to pancreatitis. Monitoring serum uric acid would not provide useful information about the patient's response to pancreatitis treatment.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Initiating a bowel regimen program is essential to avoid constipation, which can be a trigger for autonomic dysreflexia in patients with spinal cord injuries. Ensuring regular bowel movements helps prevent the discomfort and complications that can lead to this potentially life-threatening condition.
Choice B reason: Applying tight-fitting clothing is contraindicated as it can cause skin irritation, pressure sores, and other discomforts that could trigger autonomic dysreflexia. Loose and comfortable clothing is recommended to prevent these issues.
Choice C reason: Completing frequent skin checks is crucial for detecting and preventing pressure ulcers, skin infections, and other skin conditions that can act as noxious stimuli, triggering autonomic dysreflexia. Regular skin assessments help ensure early identification and management of potential issues.
Choice D reason: Restricting all patient visitors is not necessary for preventing autonomic dysreflexia. While it is important to manage the patient's environment and stress levels, complete visitor restriction is not a standard intervention for this condition.
Choice E reason: Inserting an indwelling Foley catheter is beneficial for managing bladder function and preventing urinary retention, a common trigger for autonomic dysreflexia. Continuous bladder drainage helps prevent distention and the subsequent risk of triggering this condition.
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