A nurse who is caring for a client admitted to the nursing unit ...

[elizabeth18]

A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which of the following nursing diagnoses is the highest priority for this client?
 
  A) Impaired comfort
  B) Disturbed body image
  C) Disturbed sleep pattern
  D) Activity intolerance

Question 2

A 65-year-old client visits a health care facility for a scheduled physical assessment. During the assessment, the client states that he experiences occasional shortness of breath.
 
  What suggestion could the nurse make to improve the client's respiratory function in this case? A) Avoid strenuous exercises.
  B) Use a nasal strip.
  C) Drink liberal amounts of fluids.
  D) Avoid excessive use of over-the-counter medications.

[1_Step_At_ATime]

Answer to Question 1

A
Feedback:
Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority. The client may have disturbed body image, disturbed sleep patterns, or activity intolerance, but all these are secondary to pain.

Answer to Question 2

C
Feedback:
The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. OTC medications do not normally affect respiratory function.