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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Venous stasis ulcers typically present as open sores with irregular borders. This is due to chronic venous insufficiency leading to sustained pressure in lower extremities, impairing blood flow and causing tissue breakdown. The irregular shape results from uneven tissue damage.
Choice B rationale
Dry, scaly patches of skin are indicative of other conditions, such as eczema or psoriasis, rather than venous stasis ulcers. These patches are not directly caused by impaired venous circulation or pressure-induced tissue damage.
Choice C rationale
Redness and warmth around the ulcer site can indicate infection, not the primary characteristic of venous stasis ulcers. Stasis ulcers are more commonly associated with chronic wounds and slow healing due to venous congestion.
Choice D rationale
Shiny skin with loss of hair growth is more commonly observed in arterial insufficiency rather than venous stasis ulcers. Arterial insufficiency leads to inadequate oxygen delivery to tissues, causing trophic changes like shiny skin and hair loss.
Correct Answer is A
Explanation
Choice A rationale
Cottage cheese is a complete protein, containing all nine essential amino acids. These are vital for tissue repair, enzyme synthesis, and immune function. It is also highly digestible, making it ideal for individuals with compromised health.
Choice B rationale
Oatmeal lacks all essential amino acids, particularly lysine. Although it is a healthy carbohydrate source and rich in soluble fiber, it does not qualify as a complete protein for this context.
Choice C rationale
Cooked spinach, while high in vitamins and iron, is deficient in essential amino acids like methionine. It supports general health but does not fulfill the criteria for complete proteins.
Choice D rationale
Whole wheat bread provides incomplete protein, missing essential amino acids like lysine. While nutritionally beneficial as a complex carbohydrate, it is not suitable for teaching about complete proteins.
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