A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
Acute pain related to renal calculus.
Impaired renal function related to pain.
Risk for aspiration related to vomiting.
Nutritional deficit related to nausea.
The Correct Answer is A
A. Acute pain is the most immediate and pressing problem for the client, given the reported severe flank pain. Managing pain effectively is a primary concern in nursing care, particularly for clients with renal calculi.
B. While impaired renal function is a concern with renal calculi, the acute pain takes precedence as it requires immediate intervention to enhance the client's comfort and promote better overall health.
C. The risk for aspiration is a potential issue due to nausea and vomiting; however, addressing the pain is more urgent in this scenario.
D. Nutritional deficit related to nausea is also a valid concern but is secondary to the acute pain management. The client’s immediate comfort and pain relief should be prioritized to facilitate recovery and improve overall well-being.
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Correct Answer is C
Explanation
A. Immediately after the patient has been medicated for pain.
While pain relief may help, education should be conducted when the patient is alert and comfortable, not immediately after pain medication when they may be drowsy.
B. The last thing in the evening, after visitors have left, before bedtime. Education right before bedtime may not be effective if the patient is tired, as retention and attention may be reduced.
C. When the patient is comfortable and receptive to the patient education.
Teaching should occur when the patient is comfortable, alert, and receptive to ensure they can retain and understand the information.
D. Just before the patient is discharged, so the information is current.
Waiting until discharge could overwhelm the patient, and they may not have time to ask questions or clarify information.
Correct Answer is A
Explanation
A. A headache that worsens upon sitting up is characteristic of a post-lumbar puncture headache, indicating a potential complication related to cerebrospinal fluid leakage.
B. Pain in the lower back after the procedure can be normal and does not necessarily indicate a complication.
C. Nausea and vomiting can occur but are not specific indicators of a complication following a lumbar puncture.
D. Sore throat when swallowing and talking is not typically associated with lumbar puncture complications and may relate to other causes such as anxiety or dehydration.