The client has acute pancreatitis. Which nursing intervention is the highest priority?

Correct Answer: A

Rationale: The correct answer is A: Administer pain medication as prescribed. This is the highest priority because acute pancreatitis is a painful condition, and managing pain is crucial for the client's comfort and well-being. Pain control also helps reduce stress on the pancreas and can aid in preventing complications. Choice B is incorrect because while monitoring serum amylase and lipase levels is important in diagnosing pancreatitis and assessing response to treatment, it is not the highest priority intervention. Choice C is incorrect as encouraging oral intake of clear liquids may exacerbate pancreatitis symptoms and lead to further complications. Choice D is incorrect as assessing bowel sounds, while important for monitoring gastrointestinal function, is not the highest priority in the acute management of pancreatitis.

Correct Answer: B

Rationale: The correct answer is B: Hyperpigmentation and hypotension. Addison's disease is characterized by adrenal insufficiency, leading to low cortisol and aldosterone levels. Hyperpigmentation occurs due to elevated levels of ACTH, causing melanin deposition. Hypotension results from aldosterone deficiency, leading to sodium and water loss. Choice A is incorrect because Addison's disease does not typically present with hypertension or hyperglycemia. Choice C is incorrect as exophthalmos and tachycardia are not typically associated with Addison's disease. Choice D is incorrect as weight gain and fluid retention are not common manifestations of Addison's disease.

Correct Answer: C

Rationale: The correct answer is C: Place the client in Trendelenburg position. This is the first action to take in a client with suspected air embolism, a potential complication of central line insertion. Placing the client in Trendelenburg position with the head down and the legs elevated can help prevent air from reaching the heart and lungs. This action can help stabilize the client's condition before further interventions can be implemented. Stopping the TPN infusion (choice A) can be important, but the priority in this situation is to address the potential air embolism. Notifying the healthcare provider (choice B) can be done after the immediate intervention. Administering oxygen (choice D) is important, but placing the client in Trendelenburg position takes precedence in this emergency situation.

Correct Answer: A

Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol is a first-generation antipsychotic known to cause extrapyramidal side effects, including tardive dyskinesia, which is characterized by involuntary repetitive movements of the face and body. This side effect is a serious concern due to its potential to be irreversible. Monitoring for tardive dyskinesia is crucial in clients taking haloperidol to detect and manage symptoms promptly. Explanation for incorrect choices: B: Orthostatic hypotension - This side effect is more commonly associated with other antipsychotic medications, particularly second-generation ones. C: Photosensitivity - Haloperidol does not typically cause photosensitivity as a side effect. D: Hyperglycemia - While some antipsychotic medications may lead to metabolic side effects like hyperglycemia, haloperidol is not typically associated with this specific side effect.

Correct Answer: A

Rationale: The correct answer is A: Rebound tenderness at McBurney's point. McBurney's point is located in the right lower quadrant and is a classic sign of appendicitis. Rebound tenderness at this point indicates inflammation in the peritoneum, suggesting appendicitis. Choices B, C, and D are not specific to appendicitis. Positive Murphy's sign is related to cholecystitis, Rovsing's sign is seen in acute appendicitis but is not as specific as rebound tenderness at McBurney's point, and Cullen's sign is associated with acute pancreatitis.