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?

The correct answer is choice A and E.

Choice A rationale:

The nurse should plan to ask the client what they are hearing. This is a therapeutic communication technique known as seeking clarification. It allows the nurse to gain more information and understand the client’s perspective. It can also help the client feel heard and validated, which can build trust and rapport.

Choice B rationale:

Telling the client their hallucinations are not real is not recommended. While it’s true that the hallucinations are not real, from the client’s perspective, they are very real and can be very frightening. Telling them otherwise can come across as dismissive and invalidating, which can damage the therapeutic relationship.

Choice C rationale:

Escorting the client to a group meeting may not be appropriate at this time. Given the client’s current state of agitation and confusion, they may not be able to participate effectively in a group setting. It could also potentially disrupt the group dynamic.

Choice D rationale:

Restraining the client should be a last resort and only used when the client is a danger to themselves or others. In this case, while the client is agitated and confused, they do not appear to be an immediate danger.

Choice E rationale:

Reducing excess stimulation around the client can be beneficial in this situation. Excess stimulation can exacerbate symptoms of psychosis such as hallucinations and agitation. By creating a calm and quiet environment, it can help reduce these symptoms and help the client feel more at ease.

Choice A rationale:

Hydrogen peroxide. Hydrogen peroxide is not the recommended solution for disinfecting surfaces following a blood spill. While it can be used to clean wounds and may have some disinfectant properties, it is not as effective as bleach in destroying bloodborne pathogens.

Choice B rationale:

Bleach. Bleach is the appropriate choice for disinfecting surfaces contaminated with blood. A 10% bleach solution (1 part bleach to 9 parts water) is effective at killing bloodborne pathogens such as HIV and hepatitis B and C viruses. It should be used in healthcare settings to ensure proper disinfection after a blood spill.

Choice C rationale:

Isopropyl alcohol. Isopropyl alcohol is an effective disinfectant for some purposes, but it may not be as effective as bleach against bloodborne pathogens. It is commonly used for cleaning and disinfecting skin before medical procedures but is not the recommended choice for disinfecting surfaces following a blood spill.

Choice D rationale:

Chlorhexidine. Chlorhexidine is an antiseptic solution often used for skin disinfection before surgical procedures or invasive medical interventions. It is not typically used for disinfecting surfaces contaminated with blood.