A nurse in an urgent care facility is caring for a client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition: Pancreatitis
Rationale:
The client's presentation with severe upper left quadrant abdominal pain, nausea, febrile status, tachypnea, and increased amylase and lipase levels suggests pancreatitis. Pancreatitis commonly presents with abdominal pain, nausea, and vomiting (though vomiting is not reported here), and elevated pancreatic enzymes (amylase and lipase). The elevated glucose level (200 mg/dL) may also point to pancreatitis since the pancreas plays a role in glucose metabolism.
Actions to Take:
Administer opioids for pain:
Rationale: Pain management is crucial in pancreatitis. Administering opioids like morphine or hydromorphone can help manage the severe pain, improving comfort and reducing distress.
Maintain separate equipment for the client:
Rationale: In cases of pancreatitis, particularly if caused by an infectious etiology, it is essential to avoid cross-contamination. Separate equipment reduces the risk of spreading infections if relevant.
Parameters to Monitor:
Dyspnea:
Rationale: The patient is tachypneic, and it's important to monitor for any progression of respiratory issues. Dyspnea could indicate worsening respiratory status or complications such as pleural effusion.
Hypotension:
Rationale: Hypotension can be a sign of shock, a potential complication of pancreatitis due to fluid loss, or systemic inflammatory response. It is important to monitor for signs of hypotension to ensure adequate perfusion and prevent shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Place a nonadherent dressing on the right knee abrasion: While minor abrasions should be cleaned and dressed, it is not a priority compared to managing the child's pain and fracture care.
B. Administer Ibuprofen 200 mg: Ibuprofen is an appropriate analgesic and anti-inflammatory medication to manage the child's pain (rated 5/10) and reduce swelling. Prompt pain relief is essential for the child’s comfort.
C. Apply ice packs to the fingers and along the right forearm: Applying ice helps reduce edema, pain, and inflammation at the fracture site. It also minimizes soft tissue damage.
D. Elevate the affected forearm with pillows: Elevating the arm helps reduce swelling and promotes venous return, which is essential for minimizing discomfort and preventing complications like compartment syndrome.
E. Review cast care instructions with the child's parents: Reviewing cast care is essential but should be done after the cast is applied, not at this stage of care.
F. Explain the cast application procedure to the child: This is important but not an immediate priority. The nurse should first address pain, swelling, and proper limb positioning before discussing the procedure.
Correct Answer is D
Explanation
A. Assigning tasks is important but comes after understanding family dynamics.
B. Establishing a routine is beneficial but should follow assessment.
C. Referring to a support group is valuable but not the immediate first step.
D. Determining family roles helps the nurse assess coping strategies and dynamics, which is essential before planning interventions.
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