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.

Answer and Explanation

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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Correct Answer is C

Explanation

The correct answer is: c. A client who exhibits an increase in energy.

Choice A reason: A client with psychomotor retardation may experience a visible slowing of physical and emotional reactions. This symptom is associated with major depressive disorder and can manifest as slowed speech, decreased movement, and impaired cognitive function. While psychomotor retardation is a significant symptom of depression, it is not typically identified as the highest risk factor for suicide when compared to other symptoms such as a sudden increase in energy, which can indicate a potential for acting on suicidal thoughts.

Choice B reason: An inability to concentrate is another symptom that can be present in individuals with major depressive disorder. It refers to difficulty in focusing, making decisions, or remembering things. Although this can contribute to the overall severity of depression, it is not directly linked to an increased risk of suicide as strongly as some other symptoms like changes in sleep patterns or behavior.

Choice C reason: An increase in energy in a client with major depressive disorder, especially if it occurs suddenly, can be a warning sign of potential suicidal behavior. This change can indicate that the individual has decided about suicide and may now have the energy to act on these thoughts. It is important for healthcare providers to closely monitor such changes in energy levels, as they can be indicative of an increased risk for suicide.

Choice D reason: Persistent insomnia is a common symptom in individuals with major depressive disorder and can exacerbate other symptoms of depression. Lack of sleep can lead to irritability, cognitive impairment, and can affect overall health. While it is a concerning symptom and can affect a person’s risk for suicide, it is not considered the single highest risk factor when compared to a sudden increase in energy.

A. Soiled linens are placed on the floor B. Waste containers are lined with single bags C. Dampened cloths are used for dusting the area D. Uncapped sharps are put in a puncture-resistant container

Correct Answer is A

Explanation

Placing soiled linens on the floor can lead to cross-contamination and the spread of infectious agents. This can pose a risk to the immunocompromised client, who may be more susceptible to infections.

Lining waste containers with single bags helps contain potentially infectious waste and facilitates proper disposal. This reduces the risk of contamination and exposure to infectious materials.

Using dampened cloths for dusting helps minimize the spread of dust and airborne particles. Dampening the cloth can help capture the dust and prevent it from becoming airborne, reducing the potential for respiratory exposure.

Placing uncapped sharps in a puncture-resistant container is an essential practice to prevent needlestick injuries and the transmission of bloodborne pathogens. This ensures safe disposal of sharps and reduces the risk of accidental needlestick injuries to healthcare workers and clients.

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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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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?