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A nurse in a medical-surgical unit is caring for a clent

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the

followed by the client .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for Correct Choices:

  • Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
  • Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

  • Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
  • Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
  • Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
  • Blood glucose level:  Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Rationale:

  • Monitor for elevated temperature: Epidural anesthesia can mask symptoms of infection such as chorioamnionitis. Monitoring temperature helps detect early signs of infection or epidural-related complications.
  • Assess for urinary retention: Epidural anesthesia often causes loss of bladder sensation, increasing the risk for urinary retention. Regular assessments are needed to determine when catheterization is required.
  • Assist the client with ambulation: After epidural anesthesia, lower limb motor function may be impaired. Ambulation is unsafe due to the risk of falls and injury; bedrest is generally advised until full motor function returns.
  • Inform the client to expect drowsiness: Drowsiness is not a typical side effect of epidural anesthesia; it may indicate systemic absorption or another issue. Encouraging drowsiness may mask concerning symptoms that need prompt evaluation.
  • Encourage the client to turn from side to side: Repositioning helps maintain optimal uteroplacental perfusion and prevents hypotension caused by vena cava compression from aortocaval syndrome.

Correct Answer is ["A","B","C","D"]

Explanation

Rationale:

A. Sleep pattern: Two days without sleep is a red flag in bipolar disorder and may lead to worsening mania or psychosis. Addressing sleep deprivation is a priority to reduce the risk of exhaustion or psychotic deterioration.

B. Skin turgor: Poor skin turgor suggests dehydration, which may be due to poor fluid intake or prolonged activity. It requires immediate follow-up to prevent complications like electrolyte imbalances or renal injury.

C. Hallucinations: Persistent visual hallucinations may indicate an acute psychotic episode or manic psychosis. These require immediate psychiatric intervention to ensure client safety and stabilization.

D. Heart rate: A heart rate of 120/min indicates tachycardia, possibly related to dehydration, agitation, or underlying mania. It requires prompt evaluation to rule out cardiovascular strain or systemic causes.

E. Hygiene: While poor hygiene is a concern and can indicate mental health deterioration, it is not immediately life-threatening. It can be addressed after acute issues such as dehydration, tachycardia, and psychosis are managed.

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