A client with suspected appendicitis is waiting for surgery. What should the nurse do?

Offer the client a warm beverage.

Monitor the client's gag reflex.

Help the client to a side-lying position with knees flexed.

Bring the client a heating pad to apply to the abdomen for comfort.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Offering a warm beverage to a client with suspected appendicitis is not advisable. Preoperative clients are typically required to have an empty stomach to reduce the risk of aspiration during anesthesia. Introducing fluids or food could delay surgery and increase the risk of complications.

Choice B reason:

Monitoring the client's gag reflex is not a priority in the care of a client with suspected appendicitis. The gag reflex is more relevant in neurological assessments or when evaluating swallowing function, not in the context of appendicitis.

Choice C reason:

Helping the client to a side-lying position with knees flexed can provide comfort and may help relieve abdominal pain. This position reduces tension on the abdominal muscles and can be a supportive measure while the client awaits surgery.

Choice D reason:

Applying a heating pad to the abdomen is contraindicated in clients with suspected appendicitis. Heat can cause the appendix to rupture, leading to peritonitis, which is a severe and potentially life-threatening complication. Therefore, this action should be avoided.

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Correct Answer is D

Explanation

Choice A Reason
Hyperreflexia refers to an overactive or overresponsive reflexes, which is a neurological condition and not directly related to the behaviors described. It is typically seen in conditions affecting the central nervous system and is not characterized by the inability to wait turns or interrupting conversations.

Choice B Reason
Defiance implies a conscious choice to resist authority or rules, which may not necessarily be the case here. While children with behavioral issues may exhibit defiant behaviors, the symptoms described are more indicative of a lack of impulse control rather than a deliberate choice to defy.

Choice C Reason
Inattention is a component of several behavioral and cognitive disorders, including ADHD. However, the behaviors described—blurting out answers, inability to wait for turns, and interrupting others—are more specifically associated with impulsivity rather than inattention alone.

Choice D Reason
Impulsivity is the tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences. The behaviors described—such as blurting out answers and interrupting others—are classic signs of impulsivity, which is often seen in conditions like ADHD.

A. Superficially charming. B. Friendly and open. C. Intense and impulsive. D. Guarded and suspicious. E. Guarded and suspicious.

Correct Answer is D

Explanation

Choice A Reason
A client with paranoid personality disorder is typically not described as superficially charming. This description is more often associated with other personality disorders, such as antisocial personality disorder, where individuals may use charm to manipulate others for personal gain.

Choice B Reason
Being friendly and open is generally not characteristic of paranoid personality disorder. Individuals with this disorder are often wary of others and may be perceived as cold or distant due to their mistrust.

Choice C Reason
While intensity and impulsivity can be seen in various personality disorders, they are not the defining features of paranoid personality disorder. These traits are more commonly associated with borderline personality disorder.

Choice D Reason
Guarded and suspicious are hallmark descriptors for someone with paranoid personality disorder. Individuals with this condition are often very distrustful of others, suspecting that others have ulterior motives or are out to harm them. They may be preoccupied with doubts about the loyalty or trustworthiness of friends or associates.

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A client with suspected appendicitis is waiting for surgery. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Assessment data for a 9-year-old reveals that she blurts out answers to questions before the question is completed, is unable to wait her turn, and persistently interrupts and intrudes in the conversations of others. The nurse would assess these behaviors as relating primarily to:

Correct Answer is D

Explanation

The edited text with the question and the choices labeled from a to d is as follows: The nurse who assesses a client as having paranoid personality disorder is most likely to describe the client as:

Correct Answer is D

Explanation

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