A nurse in an emergency department is caring for a client who has suspected appendicitis. Which of the following actions should the nurse plan to take?
Monitor the client for an elevated RBC count.
Instruct the client to not eat food or drink liquids.
Administer an enema to the client.
Maintain the client in a supine position.
The Correct Answer is B
A. Monitor the client for an elevated RBC count.: While an elevated white blood cell count (WBC) is more indicative of appendicitis, an elevated RBC count is not typically used to diagnose appendicitis.
B. Instruct the client to not eat food or drink liquids.: This is important as it prepares the client for a potential surgical procedure. If the appendix is inflamed and surgery is necessary, the client should not eat or drink to prevent complications related to anesthesia and surgery.
C. Administer an enema to the client.: Administering an enema is not recommended as it can increase the risk of perforation of the appendix, which is a serious complication.
D. Maintain the client in a supine position.: While maintaining a supine position may be necessary, it is not as critical as ensuring the client remains NPO (nil per os) in preparation for possible surgery. The position is less of a priority compared to dietary restrictions in this scenario.
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Related Questions
Correct Answer is D
Explanation
A) Talking with the client's family to determine how the condition affects the client role:
Understanding the client's role within the family is important for comprehensive care, but it is not the most immediate priority in discharge planning. This information can be gathered once the client has the tools to manage their condition effectively.
B) Assessing the impact of the client's body image changes:
While body image is a significant concern for many clients with chronic conditions, it does not directly affect the immediate physical ability to manage daily activities and pain, which is crucial for someone with osteoarthritis.
C) Giving the client printed information about when to use hot and cold therapy:
Providing education on managing symptoms is essential, but simply giving printed information might not address the client's immediate need for practical assistance and adaptations necessary for self-care at home.
D) Consulting occupational therapy to provide assistive devices for self-care:
Ensuring the client has access to assistive devices through occupational therapy is the priority because it directly addresses their ability to perform activities of daily living independently and safely. This intervention can significantly improve the client’s quality of life and reduce the risk of complications.
Correct Answer is D
Explanation
A) Reports intolerance to heat: Intolerance to heat is more commonly associated with conditions like hyperthyroidism rather than iron-deficiency anemia. Individuals with iron-deficiency anemia often experience fatigue and cold intolerance due to decreased oxygen-carrying capacity of the blood.
B) Develops bradycardia after eating: Bradycardia (slow heart rate) is not typically associated with iron-deficiency anemia. Anemia usually causes an increased heart rate (tachycardia) as the body tries to compensate for reduced oxygen delivery.
C) Has a friction rub on auscultation: A friction rub is a sound heard on auscultation associated with pericarditis, an inflammation of the pericardium, and is not a typical finding in iron-deficiency anemia. Anemia primarily affects the blood and does not usually cause inflammation of the heart lining.
D) Displays dyspnea while walking: Dyspnea, or shortness of breath, is a common symptom of iron-deficiency anemia, particularly with exertion. This occurs because the reduced hemoglobin levels result in decreased oxygen delivery to tissues, making physical activities more challenging and causing breathlessness.
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