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A nurse is assisting in the care of an adolescent who reports abdominal pain.

Exhibits

Complete the following sentence by using the list of options.

The nurse should first address the client's

followed by the client’s .
Answer and Explanation

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

i. Pain:

Priority: Pain is a critical factor that needs immediate attention, especially since the adolescent reports a high pain level of 9/10, which indicates severe discomfort. Unmanaged pain can lead to increased stress, anxiety, and potentially worsen the patient’s condition. The adolescent is guarding the abdomen, which indicates severe pain possibly due to an underlying issue such as appendicitis or another serious abdominal pathology. The right lower quadrant pain and positive obturator sign suggest an acute abdomen, which could be life-threatening and requires urgent attention.

ii. Heart rate:

Priority: After addressing pain, the nurse should focus on the heart rate, which is elevated at 124 beats per minute (tachycardia). Tachycardia in this context could be a response to pain or an indication of infection, dehydration, or another serious underlying condition. Given that the temperature is slightly elevated (38°C or 100.4°F), there is a possibility of an infectious process, which could be contributing to both pain and the elevated heart rate.

Other Considerations:

  • Nausea: Addressing nausea is important but secondary to the more urgent need to manage severe pain and evaluate cardiovascular stability.
  • Bowel Movement: The last bowel movement was yesterday, and the patient does not report significant changes in bowel habits, making this less urgent than the acute symptoms.
  • WBC Count: While it’s important to assess WBC count to check for infection, it’s part of a broader diagnostic workup that follows after addressing immediate symptoms.
  • Decreased Appetite: This is a symptom of the underlying condition but is not as immediate a concern as pain and heart rate in the acute setting.


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Related Questions

Correct Answer is B

Explanation

A. Test the stool for occult blood: Testing for occult blood in the stool is not relevant for diagnosing pinworms.
B. Perform a tape test: The tape test involves applying transparent tape to the perianal area to collect pinworm eggs, which is the appropriate diagnostic method for Enterobius vermicularis.
C. Initiate IV fluids: IV fluids are not indicated for the diagnosis or treatment of pinworms unless the child is severely dehydrated, which isn't suggested by the scenario.
D. Collect stool specimens for culture: Stool culture is not used to diagnose pinworms; the tape test is more appropriate.

Correct Answer is C

Explanation

A. Remove clothing. Removing clothing is important to prevent further injury from retained heat or chemicals, but it is not the first priority compared to ensuring a patent airway and adequate breathing.
B. Administer pain medication. Pain management is important but comes after ensuring the child's airway and respiratory status are stable.
C. Assess respiratory status. Burns on the face and chest can compromise the airway and breathing. Assessing respiratory status is the first priority to ensure the child’s airway is not obstructed and that they are receiving adequate oxygen.
D. Insert a Foley catheter. Inserting a Foley catheter may be necessary to monitor urine output and assess kidney function in severe burns, but it is not the first priority compared to assessing respiratory status.

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