An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating.
The nurse anticipates the client developing which acid-base imbalance?

A - The injury may require medical attention, as the mother mentioned that the boy is in pain. Correct

This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it.

The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.

B - The abrasions on the boy's leg and hand have healed.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.

C - The mother describes what she did after her child got injured.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.

D - The boy lacks coordination when answering the nurse's questions.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint.

The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inflammation.

Choice A rationale:

Domestic violence assistance is an important topic, but it falls under secondary and tertiary prevention rather than primary disease prevention, which is the focus of this community outreach program. Primary prevention aims to prevent the disease from occurring in the first place, while domestic violence assistance addresses an existing issue.

Choice B rationale:

Blood pressure screening is valuable for early detection of hypertension, but it also falls under secondary prevention. Primary prevention focuses on preventing the onset of diseases through measures such as immunizations, health education, and lifestyle modifications.

Choice D rationale:

Outreach for support group information is essential for clients with chronic conditions or specific needs. However, it is not primarily related to preventing diseases at the population level, which is the primary goal of this community outreach program. This topic may be more relevant to secondary and tertiary prevention efforts.