Exhibits
The nurse is stabilizing the client and preparing her for surgery.
What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.
Effective coping with illness related anxiety
Infection prevention related to illness
Relief of acute pain
A review of diet progression postoperatively
Promotion of bowel routine
Prevention of deep vein thrombosis (DVT) related to immobility
Fluid volume management
Client education about diagnosis and plan of care
Correct Answer : B,C,G,H
A. While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B. Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C. The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D. This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E. The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F. This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G. The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume. Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Analyze past hurts and resentments to identify the source. This strategy is more appropriate for clients in therapy to address past trauma. It is not the immediate focus for managing anxiety.
B. Concentrate on and ventilate emotions when distressed. While expressing emotions is important, it might not be the most effective strategy for generalized anxiety disorder, as it can sometimes exacerbate anxiety.
C. Focus on small achievable tasks, not taxing problems. This approach helps the client manage anxiety by breaking down large tasks into manageable steps, which reduces the overwhelming feelings associated with generalized anxiety disorder.
D. Relax and reduce the amount of effort to solve the problem. Relaxation is useful, but focusing on small, achievable tasks is a more effective way to manage anxiety in this scenario.
Correct Answer is D
Explanation
A. Speak to the healthcare provider about instituting physical therapy: Physical therapy is not necessary in the immediate period before surgery for hypertrophic pyloric stenosis.
B. Ensure placement of the nasogastric tube with an abdominal x-ray: While confirming tube placement is important, it is not a key action for maintaining growth and development.
C. Use sterile water for gastric lavage: This is not relevant to the care of a child with hypertrophic pyloric stenosis in the pre-surgical period.
D. Offer a pacifier for nonnutritive sucking: Non-nutritive sucking provides comfort and can promote normal development in infants, even in the absence of feeding.
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