During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Nothing by mouth.

Electrocardiogram.

Monitor urinary output.

Complete bed rest.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis). Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.

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Correct Answer is C

Explanation

Choice A Reason:
Purulent secretions from eyes and nares is incorrect. Purulent secretions, which are thick and yellow or green in color, typically indicate the presence of a bacterial infection rather than allergic rhinitis. Allergic rhinitis is more commonly associated with clear nasal discharge, although it can sometimes be accompanied by a mild increase in nasal secretions.
Choice B Reason:
Snoring and bilateral, pale gray nodules is incorrect. Snoring and bilateral, pale gray nodules suggest adenoid hypertrophy rather than allergic rhinitis. Adenoid hypertrophy refers to enlargement of the adenoids, which are lymphoid tissue located in the back of the nasal cavity. Enlarged adenoids can lead to snoring and the presence of grayish nodules upon examination of the nasopharynx.
Choice C Reason:
Intranasal edema and swelling of turbinates are correct. Intranasal edema (swelling inside the nose) and swelling of turbinates are characteristic features of allergic rhinitis. Allergic rhinitis results from inflammation of the nasal mucosa in response to exposure to allergens, leading to nasal congestion and swelling of the turbinates.
Choice D Reason:
Eye tearing and thick yellow nasal drainage is incorrect. Eye tearing and thick yellow nasal drainage suggest the presence of sinusitis rather than allergic rhinitis. Sinusitis is characterized by inflammation of the sinuses, which can result in symptoms such as facial pain or pressure, thick nasal discharge, and eye tearing due to sinus pressure affecting the tear ducts.

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A. Request diagnostic laboratory testing for the client. B. Obtain a dietary consultation for nutrition teaching. C. Instruct the client in the need to use iodized salt. D. Schedule a follow-up appointment in one month.

Correct Answer is A

Explanation

Choice A Reason:
Requesting diagnostic laboratory testing for the client is appropriate action. Enlargement of the thyroid gland can be indicative of various thyroid disorders, including hyperthyroidism, hypothyroidism, or thyroid nodules. Diagnostic laboratory testing, such as thyroid function tests (TFTs), thyroid antibody testing, and possibly thyroid ultrasound, can help identify the underlying cause of the thyroid enlargement. These tests can include assessments of thyroid hormone levels (T3, T4, and TSH), antibodies, and imaging studies. Requesting diagnostic laboratory testing is essential to accurately diagnose the condition and guide appropriate management and treatment.
Choice B Reason:
Obtaining a dietary consultation for nutrition teaching is inappropriate action. While nutrition can play a role in overall thyroid health, obtaining a dietary consultation for nutrition teaching is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Dietary consultation may be considered as part of comprehensive care for thyroid disorders, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice C Reason:
Instructing the client in the need to use iodized salt is inappropriate action. While iodine deficiency can contribute to thyroid disorders, instructing the client to use iodized salt is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Using iodized salt may help prevent iodine deficiency, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice D Reason:
Scheduling a follow-up appointment in one month is inappropriate action. While scheduling a follow-up appointment may be necessary for ongoing monitoring and management of thyroid disorders, it is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Further evaluation and diagnostic testing should be prioritized to determine the underlying cause of the thyroid enlargement and initiate appropriate treatment.

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During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Nursing Test Bank

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