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 {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"D"}
Explanation
Appendicitis is the most likely diagnosis, given the right lower quadrant (RLQ) pain, fever, nausea, vomiting, and CT findings of a dilated appendix with fat stranding. CT scan results confirming appendix dilation and fat stranding indicate inflammation, which is characteristic of appendicitis. WBC count is often elevated in appendicitis due to the inflammatory response and potential infection. Gastroenteritis is unlikely since there is no history of diarrhea or recent illness, and pneumonia is not relevant given the primary abdominal symptoms.
Correct Answer is ["A","B","C"]
Explanation
A. Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis (RA). A positive result supports the diagnosis of RA.
B. C-reactive protein is an inflammatory marker that is elevated in active RA, reflecting inflammation in the body.
C. Sedimentation rate (ESR) is also an inflammatory marker and is often elevated in RA, indicating active inflammation.
D. D-Dimer is a test that assesses for the presence of clot formation and breakdown. It is not used for diagnosing RA.
E. White blood cell count may be slightly elevated in RA due to inflammation, but it is not specific for RA and is less helpful in the diagnosis compared to the other tests.
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