A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
I have no appetite.
The pain hurts so much it is making me nauseous.
When I position myself on my right side, it makes the pain worse.
The pain seems to be gone now.
The Correct Answer is D
Choice A rationale
Loss of appetite is a common symptom of appendicitis due to the inflammation and irritation of the gastrointestinal tract. This symptom alone does not indicate an immediate need for intervention.
Choice B rationale
Nausea and vomiting are also common symptoms of appendicitis. The pain and inflammation can stimulate the vomiting center in the brain, leading to nausea. This symptom, while uncomfortable, does not require immediate intervention.
Choice C rationale
Pain that worsens with movement, such as positioning on the right side, is typical of appendicitis. This is due to the irritation of the peritoneum and the inflamed appendix. This symptom is expected and does not require immediate intervention.
Choice D rationale
The sudden disappearance of pain in a patient with appendicitis can indicate a rupture of the appendix. This is a medical emergency as it can lead to peritonitis, a severe and potentially life- threatening infection of the abdominal cavity. Immediate intervention is required to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The ability to comply with anticoagulant therapy for life is essential for clients undergoing mechanical valve replacement. Mechanical valves are prone to thrombus formation, which can lead to serious complications such as stroke. Therefore, lifelong anticoagulation therapy is necessary to prevent clot formation on the valve.
Choice B rationale
While body image problems may arise due to surgical scars or the presence of a mechanical valve, they are not a primary concern that needs to be assessed before surgery. The focus should be on the client’s ability to manage the medical requirements post-surgery.
Choice C rationale
The physical demands of the client’s lifestyle are important but not as critical as the ability to comply with anticoagulant therapy. The primary concern is ensuring the client can adhere to the necessary medical regimen to prevent complications.
Choice D rationale
Participation in a cardiac rehabilitation program is beneficial for recovery and improving cardiovascular health, but it is not as crucial as the ability to comply with anticoagulant therapy. The main priority is preventing thrombus formation on the mechanical valve.
Correct Answer is ["325"]
Explanation
Step 1 is to determine the total volume of fluid to be infused in the first 8 hours. According to the Parkland formula for fluid resuscitation, half of the prescribed volume is administered in the first 8 hours. Thus:
Total fluid for the first 8 hours = 5,200 mL ÷ 2 = 2,600 mL.
Step 2 is to calculate the infusion rate in mL/hr for the first 8 hours. Divide the total volume for the first 8 hours by the total time in hours:
Infusion rate = 2,600 mL ÷ 8 hr = 325 mL/hr.
Final calculated answer: 325 mL/hr.
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