An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150 mL of dark brown emesis. In which order should the nurse implement these interventions? (Arrange with the highest priority intervention on top, and lowest priority intervention on bottom.)
Elevate the head of the bed.
Complete focused assessment.
Send emesis sample to the lab.
Offer PRN pain medication
The Correct Answer is A,B,C,D
A. Elevate the head of the bed. This intervention is the highest priority to prevent aspiration and improve the client's comfort and breathing.
B. Complete focused assessment. A thorough assessment is necessary to gather more information about the client's condition and guide further interventions.
C. Send emesis sample to the lab. This helps in diagnosing the underlying cause of the dark brown emesis, which could indicate a serious gastrointestinal issue.
D. Offer PRN pain medication. Pain management is important but should be done after addressing immediate safety concerns and gathering sufficient assessment data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Hypocalcemia:
- Condition: Hypocalcemia is a condition characterized by low levels of calcium in the blood. In newborns and infants, this can occur due to inadequate intake or absorption of calcium, and it can manifest as seizures.
- Rationale: The infant was fed cow's milk, which is not recommended for infants under one year old and can interfere with calcium absorption, possibly leading to hypocalcemia. Seizures can be a symptom of severe hypocalcemia.
Actions to Take:
1. Administer oral calcium:
- Rationale: Direct administration of calcium helps to quickly elevate calcium levels in the blood, addressing the immediate cause of the seizures.
2. Educate the mother on nutrition needs:
- Rationale: It's important to educate the mother on the appropriate nutritional needs for an
infant, emphasizing the importance of breastfeeding or formula feeding instead of cow's milk, to prevent recurrence.
Parameters to Monitor:
1. Electrocardiogram:
- Rationale: Monitoring the ECG is crucial as hypocalcemia can cause cardiac arrhythmias, and the ECG can provide real-time information about the infant's cardiac status.
2. Oxygen saturation:
- Rationale: Monitoring oxygen saturation ensures that the infant maintains adequate oxygenation, especially after a seizure and during recovery, to detect any respiratory complications early.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
A. Functional Improvement: This is crucial to assess because it indicates the effectiveness of the interventions implemented, such as physical and occupational therapy, and the overall progress of the client in regaining independence in activities of daily living. Tracking functional improvements helps determine if the client's physical abilities, mobility, and self- care skills are improving over time, which is essential for their overall well-being and quality of life.
B. Psychological Assessment: This aspect is important to evaluate because it helps gauge the client's mental and emotional well-being. Elderly individuals who are subjected to neglect or mistreatment, as in this case, may experience psychological distress, such as depression, anxiety, or feelings of helplessness. Monitoring the client's psychological status allows the nurse to identify any signs of emotional distress or trauma resulting from their situation, enabling appropriate interventions to support their mental health and emotional stability.
Additionally, assessing the caregiver's psychological well-being is also crucial as they may experience stress, burnout, or emotional strain from the caregiving responsibilities, which can impact the quality of care provided to the client.
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