NCLEX-RN · Question #497
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids…
The correct answer is A. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract. (A) Relief of pain is the primary goal of nursing intervention because this client is experiencing (B) Fluid volume deficit is being treated with IV fluid replacement. (C) Knowledge deficit will not be addressed at this time because a client in acute pain is not ready (D)…
Question
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Options
- APain related to stimulation of nerve endings associated with obstruction of the pancreatic tract
- BFluid volume deficit related to vomiting and nasogastric tube drainage
- CKnowledge deficit related to treatment regimen
- DAltered nutrition: less than body requirements, related to inadequate intake associated with current
How the community answered
(18 responses)- A78% (14)
- B11% (2)
- C6% (1)
- D6% (1)
Explanation
(A) Relief of pain is the primary goal of nursing intervention because this client is experiencing (B) Fluid volume deficit is being treated with IV fluid replacement. (C) Knowledge deficit will not be addressed at this time because a client in acute pain is not ready (D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
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