A nurse is caring for a school-age child who has appendicitis. For which of the following findings should the nurse monitor as a manifestation of a perforated appendix and report to the provider?

1. 1. 1. Request that the client's family bring the client's eyeglasses from home: This is important to ensure that the client has optimal vision and can see clearly, considering their visual loss. Having their eyeglasses will improve their ability to communicate and understand their surroundings.
      2. Reorient the client often: Reorientation is important for clients who may be disoriented due to their medical condition or unfamiliar environment. Regularly reminding the client of their location, date, and situation can help them maintain orientation.
      3. Acknowledge the client's feelings: Acknowledging and validating the client's feelings can help establish rapport and promote a therapeutic relationship. It shows empathy and understanding, which can contribute to the client's overall well-being.
      4. Provide the client with information about what to expect during their care: Providing information to the client about their care helps promote autonomy and active participation in their own healthcare. It can reduce anxiety and improve the client's overall experience.
      5. Write the full date on the client's whiteboard: Clearly documenting the full date on the client's whiteboard helps the client stay oriented to the current date and time.
      6. Maintain a well-lit environment: Ensuring a well-lit environment is important, especially for clients with visual impairment. Sufficient lighting can enhance the client's ability to see and navigate their surroundings.

It's worth noting that while asking the client's partner to stay with the client as much as possible may be beneficial, it may not always be feasible or within the nurse's control. Additionally, requesting the client to have the same caregivers with every shift may not be possible due to staffing constraints.

The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
A. Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
B. Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
D. Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.