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?

Elevated temperature

Lethargy

Decreased abdominal girth

Bradycardia

Answer and Explanation

The Correct Answer is A

A nurse caring for a school-age child who has appendicitis should monitor for several manifestations of a perforated appendix and report to the provider. According to my sources, one of the major complications of appendicitis is the perforation of the appendix, which can lead to peritonitis, abscess formation, or portal pylephlebitis. Perforation generally occurs 24 hours after the onset of pain. Symptoms include a fever of 37.7⁰C or greater, a toxic appearance, and continued abdominal pain or tenderness.

B- Lethargy is not mentioned as a manifestation of a perforated appendix.

C- Decreased abdominal girth is not mentioned as a manifestation of a perforated appendix.

D- Bradycardia, which refers to a slower than normal heart rate, is also not mentioned as a manifestation of a perforated appendix.

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Correct Answer is C

Explanation

Overhearing a discussion about a client's private information is a breach of confidentiality, and it is the nurse's responsibility to address the situation promptly.

While documenting the event in the client's progress notes might be necessary in some cases, it is not the initial action to take in this scenario. Similarly, submitting an incident report to the risk manager may be required for documentation purposes, but it is not the immediate action to address the breach of confidentiality.

Informing the client of the APs' actions may not be necessary unless there is evidence that the client's privacy has been compromised or if the client specifically requests to know. However, the priority is to address the issue of the conversation between the APs and ensure that confidentiality is maintained.

A. The client has artificial flowers in the room. B. The client is assigned to a room with negative airflow. C. The client's meal tray contains hard-boiled eggs D. The client's meal tray includes ice cream with fresh fruit.

Correct Answer is D

Explanation

A. Artificial flowers in the room: While artificial flowers can harbor dust and allergens, they are not a significant risk factor for infection in a neutropenic client with HIV. The primary concern is bacterial or fungal exposure, which is unlikely to be significantly affected by artificial flowers.Still, due to the need for a highly sterile environment for neutropenic patients, artificial flowers are typically avoided in clinical settings.

B. Room with negative airflow: A room with negative airflow is designed to prevent airborne pathogens from spreading outside the room. However, this measure is more relevant for clients with contagious respiratory infections (e.g., tuberculosis).

C. Meal tray with hard-boiled eggs: Hard-boiled eggs are generally safe for most clients. However, in a neutropenic client, the risk lies more in raw or undercooked eggs due to potential bacterial contamination (e.g., Salmonella). Hard-boiled eggs are fully cooked and less likely to pose a significant risk.

D. Meal tray with ice cream and fresh fruit: This choice presents a higher risk. Neutropenic clients should avoid fresh fruits (especially unwashed) due to potential bacterial and fungal contamination. Ice cream, although pasteurized, can also harbor bacteria if not handled properly.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

Correct Answer is D

Explanation

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