0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia.
white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3]
hemoglobin: 13.9 g/dL [14–18 g/dL]
hematocrit: 41.7% [42%–52%]
The nurse reviews the clinical data and plans the client's care.
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client’s progress.
Action to Take: insert a peripheral venous access device (VAD) | obtain a stool specimen for culture and sensitivity (C & S) | prepare the client for surgery | request an order for a clear liquid diet
Potential Conditions: peritonitis | diverticulitis | appendicitis | gastroenteritis
Parameters to Monitor: lung sounds | pulse | temperature | hemoglobin and hematocrit
Action to Take: insert a peripheral venous access device (VAD) | obtain a stool specimen for culture and sensitivity (C & S) | prepare the client for surgery | request an order for a clear liquid diet
Parameters to Monitor: lung sounds | pulse | temperature | hemoglobin and hematocrit
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