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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Do you have any plan for harming yourself?
When a client expresses suicidal ideations, the nurse's priority is to assess whether the client has a specific plan for harming themselves. This question helps determine the level of immediate risk and guides the nurse's actions in providing appropriate interventions and ensuring the client's safety.:
Can you tell me about the stresses in your life? In (option B) is incorrect. While understanding the client's stressors is important in assessing their overall mental health, it may not be the priority question in this situation. The immediate concern is to assess the presence of a specific plan for self-harm.
Do you have someone to discuss your feelings with? In (option C) is incorrect. Having someone to talk to about feelings can be beneficial for the client, but it is not the priority question in this situation. The primary focus is to assess the client's immediate risk and take appropriate actions to ensure their safety.
Has anyone in your family ever died by suicide? In (option D) is incorrect. Family history of suicide can be a risk factor for suicidal ideation, but it is not the priority question in this scenario. Assessing the client's current risk and immediate plan for self-harm is more crucial to determine the necessary interventions.
Correct Answer is B
No explanation
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