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A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 C (102.6 F), heart rate of 105/min, a soft non-tender abdomen, and menses overdue my 2 days. Which of the following findings should be the nurse's priority?

A. Heart rate 105/min
B. Soft, non tender abdomen
C. Temperature
D. Overdue menses

1 Answer

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Final answer:

The nurse's priority should be the client's high temperature of 39.2 C (102.6 F), as it is a critical sign of disease that can indicate infection or pregnancy complications, and requires immediate attention compared to the other symptoms presented.

Step-by-step explanation:

In the clinical scenario presented, the nurse needs to prioritize the client's symptoms to plan effective care. The presence of a high temperature of 39.2 C (102.6 F) should be the nurse's priority. Fever is a sign of disease and can indicate an infection or other serious conditions that requires prompt attention.

Furthermore, the significant elevation in temperature, in conjunction with the overdue menses, might suggest potential pregnancy complications, such as ectopic pregnancy or miscarriage, which can also cause abdominal pain and fever.

The heart rate of 105/min is also a concern as it is above the normal range and could be a reaction to the fever or a sign of another underlying condition.

A soft, non-tender abdomen is less urgent compared to the other findings, and overdue menses by 2 days, while noteworthy, is not immediately life-threatening. Therefore, the elevated temperature, given its potential implications, is the priority to address in this client's care.

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