The client reports mid-abdominal pain rated as 7 on a scale of 1 to 10. The client states, "I haven't had a bowel movement in 4 days and have vomited once or twice.”. Which of the following should the nurse do first?

Assist the client to ambulate to promote bowel movement.

Encourage oral intake to prevent dehydration.

Administer prescribed anti-emetics.

Notify the provider for further evaluation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Ambulation can stimulate peristalsis and promote bowel movements. However, ambulation is not the priority when the client reports severe abdominal pain rated 7/10 and vomiting. These symptoms could indicate a potential obstruction or other complications, and further evaluation is essential before initiating physical activity to avoid exacerbating the condition.

Choice B rationale

Encouraging oral intake is important to prevent dehydration, particularly if the client has been vomiting. However, this is not the first intervention, as assessing the underlying cause of the symptoms takes precedence. Increasing oral intake without addressing potential gastrointestinal obstruction may worsen the client's condition.

Choice C rationale

Administering antiemetics can provide symptom relief for nausea and vomiting. However, this intervention addresses a symptom rather than identifying the underlying cause of the client's abdominal pain and vomiting. Further evaluation by a provider is necessary before symptomatic management.

Choice D rationale

Notifying the provider allows for further evaluation and timely diagnosis of the cause of the abdominal pain and vomiting, which could indicate serious conditions like bowel obstruction or ischemia. Prompt medical evaluation is essential to determine the appropriate intervention and ensure the client's safety.

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Correct Answer is C

Explanation

Choice A rationale

Jugular vein distention suggests fluid overload or congestive heart failure due to increased central venous pressure. This finding is unrelated to allergic reactions and does not indicate the need for diphenhydramine, which is an antihistamine used for allergic symptoms. Monitoring fluid balance and addressing the underlying cause of fluid overload are appropriate interventions for such cases.

Choice B rationale

Pulmonary congestion indicates fluid accumulation in the lungs, often due to left-sided heart failure or volume overload. This is not associated with allergic reactions. Diphenhydramine would not be appropriate for managing this finding as it is not effective for conditions requiring diuresis or cardiac support. Pulmonary congestion requires treatment targeting the underlying etiology, such as diuretics or afterload reduction.

Choice C rationale

Urticaria, also known as hives, is a classic symptom of an allergic reaction. It occurs due to histamine release from mast cells and basophils, leading to localized vasodilation and increased vascular permeability. Diphenhydramine is effective in managing urticaria by antagonizing histamine H1 receptors, thereby reducing itching and swelling caused by the allergic reaction.

Choice D rationale

Hypotension during a transfusion can indicate a severe transfusion reaction, such as anaphylaxis or hemolysis. While diphenhydramine might help alleviate mild allergic symptoms, hypotension requires urgent hemodynamic support and further evaluation to determine its cause. Management may include intravenous fluids, vasopressors, and stopping the transfusion.

A. Limit instructions to two steps at a time. B. Encourage independence in ADLs. C. Encourage socialization as a distractor when the client becomes agitated. D. Vary the staff providing care for the client.

Correct Answer is A

Explanation

Choice A rationale

Alzheimer's disease affects cognitive function, making it difficult for clients to process and remember complex instructions. Limiting instructions to two steps at a time reduces cognitive overload and enhances the client's ability to follow directions. This approach is supported by evidence-based guidelines for managing Alzheimer's, which emphasize simplifying tasks to match the individual's functional capabilities.

Choice B rationale

Encouraging independence in activities of daily living (ADLs) may lead to frustration and increased agitation in clients with Alzheimer's. As cognitive decline progresses, the client often lacks the ability to independently complete ADLs, requiring structured assistance to prevent anxiety and promote safety.

Choice C rationale

Using socialization as a distractor during agitation is not effective because it may overstimulate the client, worsening the agitation. Alzheimer's clients are often sensitive to changes in environment and increased activity, necessitating calm and consistent approaches during episodes of distress.

Choice D rationale

Varying staff providing care disrupts consistency and routine, which are crucial for clients with Alzheimer's. Familiar caregivers help foster trust and reduce confusion, aligning with care practices that prioritize stability and minimize anxiety caused by frequent changes in personnel.

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The client reports mid-abdominal pain rated as 7 on a scale of 1 to 10. The client states, "I haven't had a bowel movement in 4 days and have vomited once or twice.”. Which of the following should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a transfusion of packed RBCs.Which of the following findings should the nurse identify as an indication that the client should receive diphenhydramine?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has Alzheimer's disease.Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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