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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 D

Explanation

A. Regular diet, no added salt: A regular diet with no added salt does not adequately address the sodium restriction needed to manage edema in acute glomerulonephritis.
B. Low-carbohydrate, low-protein diet: Restricting carbohydrates and proteins is not typically necessary in acute glomerulonephritis unless there are specific complications.
C. Low-protein, low-potassium diet: While protein restriction may be necessary in chronic kidney disease, it is not typically the primary focus in managing acute glomerulonephritis.
D. Low-sodium, fluid-restricted: A low-sodium diet helps to reduce fluid retention and manage edema in acute glomerulonephritis. Fluid restriction may also be necessary to manage fluid balance.

Correct Answer is D

Explanation

A. Offer chicken broth: Chicken broth alone may not provide adequate electrolyte replacement and hydration needed for managing diarrhea-related dehydration.
B. Keep NPO until the diarrhea subsides: NPO status is generally not necessary unless the child is unable to tolerate oral fluids. ORT is preferred to maintain hydration.
C. Start hypertonic IV solution: Hypertonic IV solutions are not typically used for routine management of dehydration from diarrhea in children. ORT is safer and effective.
D. Assist with initiating oral rehydration therapy: Oral rehydration therapy (ORT) is the primary intervention for managing dehydration due to diarrhea in children. It helps replace lost fluids and electrolytes and is the recommended first-line treatment.

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