A nurse in a medical-surgical unit is caring for a clent
Complete the following sentence by using the lists of options.
The nurse should first address the
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for Correct Choices:
- Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
- Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.
Rationale for Incorrect Choices:
- Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
- Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
- Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
- Blood glucose level: Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Stridor: Stridor is a high-pitched airway sound typically associated with hypocalcemia due to laryngeal spasms from increased neuromuscular excitability. It is not a common feature of hypercalcemia, where muscle excitability is decreased.
B. Seizure: Seizures result from heightened neuronal activity, which occurs more frequently in hypocalcemia. Hypercalcemia depresses neural and muscular activity, making seizures an unlikely symptom.
C. Elevated hematocrit: Elevated hematocrit can occur with dehydration but is not a direct effect of high serum calcium levels. It is not considered a hallmark manifestation of hypercalcemia.
D. Personality change: Hypercalcemia affects the central nervous system, often leading to confusion, lethargy, or personality changes. These alterations occur due to the depressive effects of excess calcium on brain function.
Correct Answer is B
Explanation
Rationale:
A. Ketorolac: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation and increase the risk of bleeding, especially in clients with a history of peptic ulcer disease. It should be avoided in this population.
B. Acetaminophen: Acetaminophen is the safest option for relieving headache in clients with a history of peptic ulcers because it lacks the gastrointestinal side effects associated with NSAIDs. It provides effective pain relief without increasing ulcer risk.
C. Ibuprofen: Ibuprofen, another NSAID, also carries a high risk of gastric irritation and peptic ulcer exacerbation. Chronic or even short-term use can worsen ulcers and lead to GI bleeding.
D. Aspirin: Aspirin has strong antiplatelet effects and is highly ulcerogenic. It increases the risk of gastric mucosal damage and should be avoided in clients with known peptic ulcer disease.
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