Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse recognizes that the client has

evidenced by

. (Finding)

Answer and Explanation

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

• Appendicitis: The sudden onset of right lower quadrant pain, elevated WBC count, low-grade fever, and CT scan findings of a dilated appendix and fat stranding point to acute appendicitis. This is a common surgical emergency that requires prompt diagnosis and intervention.

• Computed tomography (CT) scan results: The CT scan is the most definitive diagnostic tool for appendicitis. A 7 mm dilated appendix with fat stranding is classic radiologic evidence of appendiceal inflammation and supports surgical consultation.

• White blood cell count: The client’s WBC is 16,000/mm³, which is elevated and indicative of a systemic inflammatory response, commonly seen in appendicitis. Leukocytosis helps confirm infection and supports imaging findings.

Rationale for Incorrect Options:

• Gastroenteritis: Typically presents with diffuse abdominal cramping, diarrhea, and vomiting, often related to foodborne illness or viral infection. The absence of diarrhea and the presence of localized RLQ pain make this diagnosis unlikely.

• Peptic Ulcer Disease: Presents with epigastric pain, often related to meals or NSAID use. Pain is typically described as burning or gnawing, and not associated with right lower quadrant tenderness or leukocytosis, which are more consistent with appendicitis.

• Red blood cells count: The RBC count is within normal limits and does not aid in diagnosing appendicitis. It may be more relevant in cases of anemia, bleeding, or systemic illness but is not diagnostic in this scenario.

• Temperature: 100.8° F (38.2° C): A low-grade fever supports the presence of inflammation or infection. While nonspecific, it adds clinical weight to the suspicion of appendicitis when correlated with WBC elevation and CT results.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Indicated:

Palpate and compare radial pulses: Comparing radial pulses helps assess vascular integrity in both upper extremities, especially important with trauma and swelling. It can identify compromised circulation, which may occur with displaced fractures or vascular compression.
Provide morphine 2 mg IV push: The client reports severe, constant pain (10/10) in the left arm. Morphine is prescribed and appropriate for controlling acute, post-traumatic pain and preventing complications related to stress and poor pain control.
Administer ondansetron 4 mg IV push: The client reports nausea and fear of vomiting postoperatively. Ondansetron is an antiemetic used to prevent aspiration and reduce discomfort in post-op clients, especially those with limited mobility or recent anesthesia.
Check capillary refill on bilateral upper extremities: Capillary refill is part of neurovascular assessment, which is essential in clients with fractures. It helps detect early signs of impaired perfusion or compartment syndrome, particularly when swelling or displacement is present.
Inspect the bandage for drainage: Postoperative monitoring of the surgical site is critical to detect signs of bleeding, infection, or excessive drainage. Early inspection helps ensure prompt intervention if complications arise.

Contraindicated:

Perform range of motion: Performing ROM on a limb with a displaced humeral fracture is unsafe. Movement can worsen the fracture, increase pain, or disrupt surgical repairs, especially in the acute post-injury or post-op phase.

A. Inform him that the nurse is busy admitting a new client and will talk to him later. B. Encourage him to go to the nurse's station and talk with another nurse. C. Introduce him to the newly admitted client and ask him to join in the conversation. D. Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client.

Correct Answer is A

Explanation

A. Inform him that the nurse is busy admitting a new client and will talk to him later: Setting clear and respectful boundaries is crucial when working with clients who have antisocial behavior. This response maintains structure, discourages manipulation, and communicates that the nurse will respond at an appropriate time.

B. Encourage him to go to the nurse's station and talk with another nurse: Redirecting may appear dismissive and does not help reinforce boundaries. It may also escalate the client’s behavior if he feels ignored or shuffled around.

C. Introduce him to the newly admitted client and ask him to join in the conversation: Involving a client with antisocial traits in another’s admission may be inappropriate and intrusive. It risks violating the new client’s privacy and could create discomfort or safety concerns.

D. Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client: Ignoring the behavior entirely can be perceived as disrespectful or provoke escalation. Structured, assertive communication is more effective than silence.

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Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has ____ evidenced by ____. (Finding)

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Patient Data Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is A

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

The client who has emphysema and recently experienced a stroke receives a prescription for a metered-dose inhaler with a spacer device. The client asks the nurse if using the spacer is necessary. Which information should the nurse provide?

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse recognizes that the client has

evidenced by

. (Finding)