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A nurse is assisting in the care of an adolescent who reports abdominal pain.

Exhibits

Complete the following sentence by using the list of options.

The nurse should first address the client's

followed by the client’s .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

i. Pain:

Priority: Pain is a critical factor that needs immediate attention, especially since the adolescent reports a high pain level of 9/10, which indicates severe discomfort. Unmanaged pain can lead to increased stress, anxiety, and potentially worsen the patient’s condition. The adolescent is guarding the abdomen, which indicates severe pain possibly due to an underlying issue such as appendicitis or another serious abdominal pathology. The right lower quadrant pain and positive obturator sign suggest an acute abdomen, which could be life-threatening and requires urgent attention.

ii. Heart rate:

Priority: After addressing pain, the nurse should focus on the heart rate, which is elevated at 124 beats per minute (tachycardia). Tachycardia in this context could be a response to pain or an indication of infection, dehydration, or another serious underlying condition. Given that the temperature is slightly elevated (38°C or 100.4°F), there is a possibility of an infectious process, which could be contributing to both pain and the elevated heart rate.

Other Considerations:

  • Nausea: Addressing nausea is important but secondary to the more urgent need to manage severe pain and evaluate cardiovascular stability.
  • Bowel Movement: The last bowel movement was yesterday, and the patient does not report significant changes in bowel habits, making this less urgent than the acute symptoms.
  • WBC Count: While it’s important to assess WBC count to check for infection, it’s part of a broader diagnostic workup that follows after addressing immediate symptoms.
  • Decreased Appetite: This is a symptom of the underlying condition but is not as immediate a concern as pain and heart rate in the acute setting.


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Related Questions

Correct Answer is C

Explanation

A. Test the urine for ketones. While testing for ketones can be part of illness management in diabetes, it is not as immediate an action as contacting a healthcare provider when blood glucose levels are very high.
B. Withhold insulin dose if feeling nauseous. Insulin should not be withheld due to nausea. It is important to maintain insulin to control blood glucose levels even when feeling unwell. Adjustments to insulin may be necessary based on blood glucose levels and food intake.
C. Notify the provider if blood glucose levels are over 350 mg/dL. Blood glucose levels over 350 mg/dL are concerning and may indicate the need for medical intervention to prevent complications like diabetic ketoacidosis. The healthcare provider should be notified.
D. Limit fluid intake during meal time. Adequate fluid intake is important, especially when blood glucose levels are high, to help prevent dehydration and facilitate glucose clearance. Limiting fluids is not appropriate.

Correct Answer is C

Explanation

A. "Give your infant an oral rehydration solution." While rehydration is important, projectile vomiting could indicate a more serious underlying issue that needs medical evaluation.
B. "You might want to try switching to a different formula." Formula intolerance is less likely to cause projectile vomiting. A change in formula should not be suggested without ruling out more serious conditions first.
C. "Bring your infant into the clinic today to be seen." Projectile vomiting in an infant, especially when followed by hunger, can indicate pyloric stenosis, a condition that requires prompt medical evaluation. The infant should be seen by a healthcare provider to determine the cause and initiate appropriate treatment.
D. "Burp your child more frequently during feedings." Burping can help with regular gas and minor feeding issues, but it is unlikely to resolve projectile vomiting.

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