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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 C

Explanation

A. Wash bed linens in cold water. Washing bed linens in cold water is ineffective for killing pinworm eggs. Hot water should be used to properly sanitize linens and kill the eggs.
B. Clean the bathroom with bleach solution. While cleaning the bathroom with bleach can help reduce contamination, it is not a primary or effective measure for preventing pinworm spread and reinfection in a household setting.
C. Keep children's nails short. Keeping nails short reduces the likelihood of the child scratching the perianal area, where pinworm eggs are deposited, and then ingesting the eggs through hand-to-mouth contact. This helps prevent the spread and reinfection of pinworms.
D. Dress child in loose-fitting underwear. Loose-fitting underwear does not specifically help in preventing the spread or reinfection of pinworms. Tight-fitting underwear may actually be better to prevent the spread of eggs to other surfaces.

Correct Answer is D

Explanation

A. Insulin is absorbed most rapidly when injected in the thigh. Insulin is actually absorbed most rapidly in the abdomen, not the thigh.
B. Use cold insulin for injection to minimize site pain. Insulin should be at room temperature for injection to reduce discomfort and avoid altered absorption rates. Cold insulin can increase injection pain.
C. Massage the site after injection to promote absorption. Massaging the injection site can cause unpredictable insulin absorption and is not recommended.
D. Rotate the injection site to keep insulin levels consistent. Rotating the injection sites helps prevent lipodystrophy and ensures consistent insulin absorption. It helps maintain stable blood glucose levels.

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