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 ["B","C"]
Explanation
Choice A reason: Retinopathy is not a potential issue for a child who has leukemia, as it is a condition that affects the blood vessels of the retina, which can be caused by diabetes, hypertension, or sickle cell disease. Leukemia does not affect the retina, but it can cause blurred vision, eye pain, or headaches due to increased intracranial pressure or cranial nerve involvement.
Choice B reason: Hemorrhage is a potential issue for a child who has leukemia, as it is a condition that causes excessive bleeding, which can be caused by thrombocytopenia, coagulopathy, or bone marrow suppression. Leukemia can cause a low platelet count, which impairs the blood clotting process and increases the risk of bleeding from minor injuries, mucous membranes, or internal organs.
Choice C reason: Neuropathy is a potential issue for a child who has leukemia, as it is a condition that affects the nerves, which can be caused by chemotherapy, radiation, infection, or compression. Leukemia can cause nerve damage, which can result in numbness, tingling, pain, or weakness in the extremities, face, or trunk.
Choice D reason: Rheumatoid arthritis is not a potential issue for a child who has leukemia, as it is a condition that affects the joints, which can be caused by an autoimmune disorder, inflammation, or infection. Leukemia does not affect the joints, but it can cause bone pain, swelling, or fractures due to bone marrow infiltration or osteoporosis.
Correct Answer is A
Explanation
Choice A reason: Bleeding precaution is indicated for a child who has leukemia and a critically low platelet count, as it reduces the risk of hemorrhage and injury. The nurse should monitor the child for signs of bleeding, such as petechiae, ecchymosis, epistaxis, hematuria, and melena. The nurse should also avoid invasive procedures, use soft-bristled toothbrushes, apply pressure to venipuncture sites, and administer platelet transfusions as prescribed.
Choice B reason: Droplet precaution is not indicated for a child who has leukemia and a critically low platelet count, unless the child has a respiratory infection that is transmitted by droplets. Droplet precaution involves wearing a mask when within 3 feet of the child, and placing the child in a private room or with a roommate who has the same infection.
Choice C reason: Neutropenic precaution is indicated for a child who has leukemia and a critically low neutrophil count, as it reduces the risk of infection and sepsis. Neutropenic precaution involves placing the child in a private room with positive pressure airflow, wearing gloves, gown, and mask when entering the room, and restricting visitors who are ill or immunocompromised.
Choice D reason: Contact precaution is not indicated for a child who has leukemia and a critically low platelet count, unless the child has a skin or wound infection that is transmitted by direct or indirect contact. Contact precaution involves wearing gloves and gown when entering the room, and placing the child in a private room or with a roommate who has the same infection.
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