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Exhibits

What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Effective coping with illness related anxiety

Infection prevention related to illness

Relief of acute pain

A review of diet progression postoperatively

Promotion of bowel routine

Prevention of deep vein thrombosis (DVT) related to immobility

Fluid volume management

Client education about diagnosis and plan of care

Answer and Explanation

Correct Answer : B,C,G,H

A.   While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B.   Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C.   The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D.   This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E.   The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F.   This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G.   The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume.

Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","E","G","H"]

Explanation

A. Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B. Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.

C. A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D. Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E. Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F. Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G. Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H. Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I. A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.

A. Rounded spine from head to hips without concave curves. B. Posterior curvature that is convex in the thoracic area. C. Excessive concave curvature of the lumbar spine. D. Lateral curvature that creates asymmetry of the shoulders.

Correct Answer is C

Explanation

A. This describes a normal spine alignment.

B. This describes kyphosis, not lordosis.

C. Lordosis is an excessive inward curvature of the lumbar spine, often called "swayback."
D. This describes scoliosis, not lordosis.

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Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

Correct Answer is ["A","C","E","G","H"]

Explanation

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student's screening record?

Correct Answer is C

Explanation

A client who is participating in an anger management assignment asks to make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?

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Exhibits Nursing actions: Indicated/contraindicated/non-urgent

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

Which is the priority nursing problem for a client with hypoparathyroidism?

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

An older adult client who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care?

Exhibits

What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.