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
dropdown
followed by the client’s
dropdown
.

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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Correct Answer is D

Explanation

A. Maintain a saline-lock.Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
C. A no-salt-added diet is important to help manage fluid retention and hypertension, which are common in acute glomerulonephritis. However, while important, it does not take immediate priority over assessing the child's fluid status.
D. Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.

A. Regular diet, no added salt B. Low-carbohydrate, low-protein diet C. Low-protein, low-potassium diet D. Low-sodium, fluid-restricted

Correct Answer is D

Explanation

A. Regular diet, no added salt: A regular diet with no added salt does not adequately address the sodium restriction needed to manage edema in acute glomerulonephritis.
B. Low-carbohydrate, low-protein diet: Restricting carbohydrates and proteins is not typically necessary in acute glomerulonephritis unless there are specific complications.
C. Low-protein, low-potassium diet: While protein restriction may be necessary in chronic kidney disease, it is not typically the primary focus in managing acute glomerulonephritis.
D. Low-sodium, fluid-restricted: A low-sodium diet helps to reduce fluid retention and manage edema in acute glomerulonephritis. Fluid restriction may also be necessary to manage fluid balance.

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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 dropdown followed by the client’s dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

Correct Answer is D

Explanation

A nurse is caring for a school-age child who has acute glomerulonephritis. The child has peripheral edema and is producing 35 mL of urine per hour. Which of the following diets should the nurse anticipate the provider will prescribe?

Correct Answer is D

Explanation

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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
dropdown
followed by the client’s
dropdown
.