A nurse in an emergency department is assisting a provider who is assessing a client who has suspected appendicitis. Which of the following findings should the nurse expect?
Positive leukocyte esterase
Increased pain upon release of abdominal palpation
WBC 9,500 mm3
Pain from flexion of the left thigh when lying on the right side
The Correct Answer is C
A) Administering risperidone 25 mg IM: Administering risperidone intramuscularly is generally used for managing severe psychotic symptoms and not typically indicated for acute panic attacks. Without prior prescription or proper assessment, this action may be unsafe and inappropriate.
B) Teaching the client how to perform guided imagery: Guided imagery is an effective technique for managing anxiety over the long term, but it is not suitable for immediate relief during a severe panic attack. The client may not be able to focus or learn new techniques when experiencing extreme distress.
C) Staying with the client until the panic attack subsides: Providing immediate emotional support and reassurance by staying with the client helps reduce the intensity of the panic attack. The nurse's presence can help the client feel safer and more secure, facilitating a return to a calmer state.
D) Encouraging the client to take quick, shallow breaths: Quick, shallow breaths can exacerbate hyperventilation and increase symptoms like dizziness and lightheadedness. It is more beneficial to encourage slow, deep breathing to help regulate breathing patterns and reduce panic symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "Limit sodium intake to 3,500 milligrams per day.":
Limiting sodium intake is crucial for managing heart failure to prevent fluid retention and exacerbation of symptoms. However, the recommended limit is typically much lower, around 1,500 to 2,000 milligrams per day, not 3,500 milligrams.
B) "Take ibuprofen for discomfort.":
Ibuprofen and other NSAIDs are not recommended for clients with heart failure as they can cause fluid retention, worsen heart failure symptoms, and increase the risk of kidney problems. Alternatives such as acetaminophen are generally safer for pain relief.
C) "Increase the distance you walk by 100 feet daily, even if you feel fatigued.":
While regular exercise is important, clients with heart failure should not push through fatigue, as overexertion can lead to worsening symptoms. Exercise recommendations should be tailored to the individual's tolerance and should be adjusted based on their energy levels.
D) "Include no more than 2,000 milliliters of fluid intake in 24 hours.":
Restricting fluid intake to 2,000 milliliters per day helps prevent fluid overload, which is critical for managing heart failure. Monitoring and limiting fluid intake can help control symptoms such as edema and shortness of breath.
Correct Answer is C
Explanation
A) Cimetidine: Cimetidine is an H2 receptor antagonist used to reduce stomach acid and treat conditions such as peptic ulcers and gastroesophageal reflux disease (GERD). It is not used to manage metabolic acidosis.
B) Calcitonin: Calcitonin is used to regulate calcium levels and treat conditions like osteoporosis or hypercalcemia. It does not address metabolic acidosis and is not appropriate for this condition.
C) Sodium bicarbonate: Sodium bicarbonate is commonly used to treat metabolic acidosis. It works by neutralizing excess acid in the blood, thereby increasing the blood's pH and helping to correct the acid-base imbalance associated with metabolic acidosis.
D) Sodium chloride: Sodium chloride is a salt that can be used to manage fluid and electrolyte imbalances but does not correct metabolic acidosis. It is not suitable for treating the acid-base imbalance seen in metabolic acidosis.
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