A nurse is assessing a child who has appendicitis. Which of the following findings should the nurse expect?
Pain
High fever
Constipation
Bradycardia
The Correct Answer is A
Choice A reason: Pain is an expected finding for a child who has appendicitis, as it is caused by the inflammation and infection of the appendix, which is a small pouch attached to the cecum. Pain usually begins around the umbilicus and then shifts to the right lower quadrant, and it may worsen with movement, coughing, or deep breathing.
Choice B reason: High fever is not an expected finding for a child who has appendicitis, as it indicates a severe infection or a perforation of the appendix, which can lead to peritonitis or sepsis. A mild fever may be present in some cases of appendicitis, but it is not a specific or reliable sign.
Choice C reason: Constipation is not an expected finding for a child who has appendicitis, as it is not related to the function or location of the appendix. Constipation may be caused by many other factors, such as dehydration, diet, medication, or bowel habits. Diarrhea may occur in some cases of appendicitis, but it is also not a specific or reliable sign.
Choice D reason: Bradycardia is not an expected finding for a child who has appendicitis, as it indicates a decreased heart rate, which can be a sign of shock, hypothermia, or cardiac problems. Bradycardia is defined as a heart rate below 60/min in children older than 1 year, or below 100/min in infants younger than 1 year. Tachycardia, or an increased heart rate, may occur in some cases of appendicitis, as a result of pain, fever, or dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A child with Hirschsprung disease may need a feeding tube after the surgery to provide adequate nutrition and hydration while the bowel recovers. The parent should express interest in learning how to use and care for the feeding tube, as this indicates an understanding of the teaching.
Choice B reason: A child with Hirschsprung disease will not need a urinary catheter after the surgery, unless there is a specific indication for it. The parent should not confuse the feeding tube with the urinary catheter, as this indicates a lack of understanding of the teaching.
Choice C reason: A child with Hirschsprung disease will not have normal bowel movements immediately after the surgery, as the bowel needs time to heal and adapt. The parent should be aware of the possible complications and follow-up care that the child will need.
Choice D reason: A child with Hirschsprung disease may require a temporary or permanent ostomy, depending on the extent of the bowel affected. The parent should be prepared for either outcome and not assume that the ostomy is only temporary.
Correct Answer is B
Explanation
Choice A reason: A 13% weight loss is not a finding of severe dehydration, but rather of moderate dehydration. Severe dehydration is characterized by a weight loss of more than 15%.
Choice B reason: A rapid pulse is a finding of severe dehydration, as the body tries to compensate for the fluid loss and maintain the blood pressure.
Choice C reason: A bulging anterior fontanel is not a finding of severe dehydration, but rather of increased intracranial pressure. A sunken anterior fontanel is a sign of severe dehydration, as the brain tissue loses water and shrinks.
Choice D reason: Moist mucous membranes are not a finding of severe dehydration, but rather of normal hydration. Dry mucous membranes are a sign of severe dehydration, as the body loses water and electrolytes.
Choice E reason: Decreased urine output is a finding of severe dehydration, as the kidneys try to conserve water and produce less urine. This can lead to renal failure if not corrected.
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