Nokea
The nurse is caring for a client with appendicitis experiencing pain. Which pain relief method would be inappropriate for this client?
- A. Applying ice packs to the abdomen
- B. Practicing breathing exercises with the patient
- C. Using a heating pad on the abdomen
- D. Encouraging rest
Correct Answer: C
Rationale: Using a heating pad on the abdomen is inappropriate for a client with appendicitis as it may increase inflammation or risk perforation of the appendix. Ice packs, breathing exercises, and rest are safer and more appropriate for pain management.
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The following scenario applies to the next 1 items
The nurse in the emergency department (ED) cares for a 21-year-old male client
Item 1 of 1
Nurses' Notes
1650: Client reports severe abdominal pain that radiates to his left shoulder. The client was tossing around the football with friends, and after being tackled, he began experiencing intense pain that worsened. He denies any medical history but is currently being treated for infectious mononucleosis and 'needed to get some fresh air,' so he started playing football with friends. During the assessment, the client was alert and fully oriented. He reports his abdominal pain is in the left upper quadrant, which radiates to his shoulder, as an 8/10 on the Numerical Rating Scale. Slight bruising was noted on the client's abdomen. A blotchy rash was observed on his back. His abdomen was slightly distended, taut, and tender to touch. Lung sounds are clear bilaterally. Peripheral pulses 2+. Skin is hot to the touch. Cervical lymphadenopathy is present. Vital signs: T 100.4°F (38°C), P 110, RR 21, BP 115/76.
Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. Reports of abdominal pain
- B. Temperature
- C. Pulse
- D. Rash
- E. Cervical lymphadenopathy
- F. Abdominal assessment findings
Correct Answer: A,C,F
Rationale: Severe abdominal pain (A), elevated pulse (C), and abnormal abdominal findings (F) such as distention and tenderness suggest a serious condition like a ruptured spleen, especially given the history of trauma and infectious mononucleosis. These require urgent evaluation.
The nurse prepares a client for a computed tomography (CT) scan of their abdomen and pelvis with intravenous (IV) contrast. The nurse should take which action before the client's exam?
- A. Remove any medicated patches before the exam
- B. Instruct the client to empty their bladder right before the test
- C. Educate the client that they may experience a flushing sensation during the exam
- D. Assess the client for an implantable pacemaker
Correct Answer: C
Rationale: Educating about the flushing sensation (C) prepares the client for the common effect of IV contrast. Patches (A) are not routinely removed, emptying the bladder (B) is not critical, and pacemakers (D) are relevant for MRI, not CT.
The emergency department (ED) nurse reviews the client's triage note. Select the findings in the triage note that require immediate follow-up.
- A. 56-year-old male reports persistent nausea and vomiting that has not improved with prescribed anti-emetic.
- B. He reports being diagnosed with viral gastroenteritis three days ago by his physician.
- C. He states that his n/v has gotten so bad that he cannot hold down food or fluids.
- D. On assessment, the client is lethargic and oriented. Unsteady gait.
- E. He reports that he can take his prescribed medications with sips of water.
- F. On assessment, the client is lethargic and oriented. Unsteady gait.
- G. Vital signs: T 99°F (37°C), P 108, RR 18, BP 132/77, pulse oximetry reading 97% on room air.
Correct Answer: A,C,D,F
Rationale: Persistent nausea/vomiting (A, C), lethargy, and unsteady gait (D, F) suggest dehydration or electrolyte imbalances requiring immediate follow-up.
The nurse is caring for a client with a hiatal hernia who is being discharged today. The nurse talks to them regarding methods to manage symptoms and promote overall well-being associated with their condition. Which of the following statements from the client indicate that teaching is successful?
- A. I need to wear loose-fitting clothes.
- B. After a meal, I must lie down to avoid dumping syndrome.
- C. I need to eat three large meals a day.
- D. I can go to my favorite Indian restaurant anytime of the week.
Correct Answer: A
Rationale: Wearing loose-fitting clothes (A) reduces pressure on the stomach, helping manage hiatal hernia symptoms. Lying down after meals (B) can worsen reflux, large meals (C) increase symptoms, and spicy foods (D) may exacerbate reflux.
The nurse is admitting a client newly diagnosed with acute pancreatitis. The nurse should anticipate a prescription for which medication?
- A. 3% saline infusion
- B. Fentanyl
- C. Diphenoxylate-atropine
- D. Sucralfate
Correct Answer: B
Rationale: Fentanyl is used for pain management in acute pancreatitis, which is often severe. 3% saline is not standard, diphenoxylate-atropine treats diarrhea (not a primary symptom), and sucralfate is for ulcers, not pancreatitis.