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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
Performing a bladder scan can help determine the volume of urine in the bladder and assess for urinary retention, which could contribute to bladder spasms. However, this is not typically the first intervention. The priority is to ensure that the catheter is patent and draining correctly, as blockages can cause immediate discomfort and increased spasms
Choice B Reason
Stopping the irrigation could be considered if there is a concern that the CBI is contributing to the spasms. However, this would not be the first action taken. It is essential first to assess the catheter's patency and the flow of the irrigation to rule out any obstruction or kinking causing the spasms.
Choice C Reason
Administering an oral analgesic may help alleviate the discomfort caused by bladder spasms, but it does not address the underlying cause. Pain relief is important, but the initial step should be to check for and resolve any mechanical issues with the catheter system that could be causing the spasms.
Choice D Reason
Ensuring that the catheter is draining properly is the first and most crucial intervention. If the catheter is blocked or kinked, it can cause bladder distention and increased spasms. Checking the catheter's patency and the flow of irrigation can quickly resolve the issue and provide relief to the patient. If the catheter is found to be obstructed, resolving the blockage can decrease the severity of the spasms and improve the patient's comfort.
Correct Answer is A
Explanation
Choice A Reason:
Autism Spectrum Disorder (ASD) is characterized by challenges with social skills, repetitive behaviors, and communication difficulties. Jaw clenching and rocking are forms of self-stimulatory behavior (stimming) often observed in individuals with ASD¹³¹⁴. These behaviors can serve as a coping mechanism to manage sensory overload or express emotions.
Choice B Reason:
Stereotypic Movement Disorder involves repetitive, seemingly purposeless movements. While jaw clenching and rocking could be symptoms, they are more commonly associated with ASD. Stereotypic Movement Disorder is typically diagnosed when these behaviors interfere significantly with normal activities or result in self-harm, which is not mentioned in the child's description.
Choice C Reason:
Attention Deficit Hyperactivity Disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. The behaviors described, jaw clenching and rocking, are not typical indicators of ADHD, which more commonly includes symptoms like difficulty staying focused, hyperactivity, and impulsive actions.
Choice D Reason:
Intellectual Disability Disorder is characterized by limitations in intellectual functioning and adaptive behavior, which covers a range of everyday social and practical skills. The behaviors of jaw clenching and rocking do not directly indicate Intellectual Disability Disorder. This condition is usually identified by deficits in intellectual and adaptive functioning, not by specific behaviors like those described.
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