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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: 60 beats per minute is too low for an infant's apical heart rate. The normal range for a 6-month-old infant is 100 to 160 beats per minute. A low heart rate can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice B reason: 80 beats per minute is also too low for an infant's apical heart rate. The normal range for a 6-month-old infant is 100 to 160 beats per minute. A low heart rate can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice C reason: 100 beats per minute is the lower limit of the normal range for a 6-month-old infant's apical heart rate. The nurse should withhold the dose of digoxin if the infant's apical heart rate is less than 100 beats per minute, as this can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice D reason: 120 beats per minute is within the normal range for a 6-month-old infant's apical heart rate. The nurse does not need to withhold the dose of digoxin if the infant's apical heart rate is 120 beats per minute, as this does not indicate digoxin toxicity. However, the nurse should still monitor the infant's heart rate, blood pressure, and digoxin level closely, as digoxin has a narrow therapeutic window and can cause adverse effects even at therapeutic doses.
Correct Answer is D
Explanation
Choice A reason: Blood pressure is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as cardiac output, vascular resistance, and blood volume. Blood pressure may not change significantly until the fluid loss is severe and the compensatory mechanisms are overwhelmed.
Choice B reason: Respiratory rate is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as oxygen demand, carbon dioxide levels, acid-base balance, and respiratory infections. Respiratory rate may increase as a result of fluid loss, but it is not a specific or sensitive sign.
Choice C reason: Skin integrity is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as age, nutrition, hydration, and skin diseases. Skin integrity may deteriorate as a result of fluid loss, but it is not a quantitative or objective measure.
Choice D reason: Body weight is the most reliable indicator of fluid loss, as it reflects the changes in the total body water and electrolytes. Body weight can be measured easily and accurately, and it can be compared with the previous or baseline values. A loss of more than 5% of the body weight indicates moderate dehydration, and a loss of more than 10% indicates severe dehydration.
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