A nurse is caring for an adolescent who has abdominal pain.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client&
_

Answer and Explanation

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

Pain: The client reports severe pain (9/10) and is exhibiting guarding and physical signs of distress (rocking in bed and wringing hands). Pain in the right lower quadrant, along with a positive obturator sign, suggests appendicitis or another acute abdominal issue, making pain management critical for comfort and further assessment.

Nausea: The client reports nausea and a single episode of emesis. Unmanaged nausea can contribute to dehydration, delay oral intake, and worsen overall discomfort.

Incorrect answers:

Heart rate: The elevated heart rate (104/min) is likely a physiological response to pain, fever, or stress. Addressing pain will indirectly help reduce the heart rate.
WBC count: Although elevated (13,500/mm³), the WBC count confirms an inflammatory response but is not an immediate concern requiring direct intervention. The nurse will address this indirectly through further diagnostics and treatment.
Bowel movement: While the absence of a bowel movement may provide diagnostic information, it is not an immediate concern compared to the client's acute pain and nausea.
Decreased appetite: Decreased appetite is a secondary symptom and not a priority over acute pain and nausea. It will likely resolve once the underlying issue is treated.

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Correct Answer is B

Explanation

A. Provide relief from pain and discomfort: While pain management is important, maintaining immobilization and alignment is more critical for proper bone healing.

B. Maintain immobilization and alignment: Proper alignment and immobilization prevent further injury, promote healing, and support functional recovery.

C. Provide optimal nutrition and hydration: Good nutrition is essential for healing but is not the highest priority compared to ensuring immobilization and alignment.

D. Promote independence in activities of daily living: This is a long-term goal but not an immediate priority during the healing process.

A. Withhold oral fluids and food. B. Assist the client to a side-lying position. C. Provide oral hygiene. D. Auscultate the client's lungs.

Correct Answer is C

Explanation

A. Withhold oral fluids and food: Acute pancreatitis requires the pancreas to rest, which involves withholding oral intake to reduce pancreatic enzyme activity.

B. Assist the client to a side-lying position: This is a comfort measure but is not the priority intervention after managing pain.

C. Provide oral hygiene: While important to address oral dryness during NPO status, it is not the immediate priority.

D. Auscultate the client's lungs: Lung assessment is essential, especially for potential respiratory complications, but pancreatic rest takes precedence initially.

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A nurse is caring for an adolescent who has abdominal pain. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's ___ followed by the client& ___

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A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

Correct Answer is C

Explanation

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A nurse is caring for an adolescent who has abdominal pain.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client&
_