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?
Bradycardia.
Elevated temperature.
Lethargy.
Decreased abdominal girth.
The Correct Answer is B
The correct answer is Choice B.
Choice A rationale: Bradycardia is not typically associated with a perforated appendix. Instead, tachycardia (increased heart rate) may occur due to pain and infection-related systemic responses. Bradycardia could indicate other unrelated medical issues and should still be monitored.
Choice B rationale: Elevated temperature is a key sign of infection and inflammation, which are common with a perforated appendix. The release of bacteria into the abdominal cavity can cause peritonitis, leading to fever as part of the body's immune response.
Choice C rationale: Lethargy can be a nonspecific symptom and may occur in various conditions. While it can be associated with severe infection, it is not a definitive indicator of a perforated appendix. Monitoring for more specific signs, like fever and pain, is crucial.
Choice D rationale: Decreased abdominal girth is unlikely and not indicative of a perforated appendix. Instead, an increase in abdominal girth due to fluid accumulation (ascites) or air (from perforation) would be more concerning and should be reported promptly.
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Related Questions
Correct Answer is D
Explanation
The correct answer is d. To cremate the client’s body.
Choice A reason: This choice is incorrect because Hinduism does not generally prohibit medical personnel from touching the deceased’s body. In fact, it is customary for family members to prepare the body for cremation, which may include washing and dressing.
Choice B reason: This statement is incorrect as there is no specific tradition in Hinduism that requires the family to stay with the body for 8 hours following death.
Choice C reason: This option is incorrect because Hinduism typically does not prescribe burial within 24 hours of death. While some religions have specific time frames for burial, Hinduism generally prefers cremation over burial.
Choice D reason: This is the correct choice. Cremation is preferred in Hinduism and is usually performed as soon as possible, traditionally by the next day. It is believed to release the soul and help in its onward journey.
Correct Answer is B
Explanation
Choice A rationale:
Positioning the client supine with legs elevated is not an appropriate intervention for a client with ascites due to cirrhosis. It may help with other conditions, but in ascites, it can increase pressure on the abdomen and worsen fluid accumulation.
Choice C rationale:
Restricting the client's sodium intake to 3g per day is a valid intervention for a client with ascites due to cirrhosis. However, measuring the abdominal girth daily is a more immediate and actionable intervention to monitor the progression of ascites and adjust treatment accordingly.
Choice D rationale:
Keeping the client's daily protein intake below 0.8 g/kg is not the standard practice for managing ascites in cirrhosis. In fact, adequate protein intake is important to prevent malnutrition in these clients, so protein restriction is not recommended unless specifically indicated by a healthcare provider.
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