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 D
Choice A rationale:
Bradycardia (slow heart rate) is not typically associated with a perforated appendix. Instead, tachycardia (increased heart rate) is a more common finding due to the body's response to infection and inflammation. Therefore, choice A is not the correct answer.
Choice B rationale:
An elevated temperature (fever) is a common manifestation of appendicitis, especially when it progresses to perforation. This is because infection and inflammation in the abdominal cavity can lead to fever as the body's immune response. While it is a concern, it is not specifically indicative of a perforated appendix. Therefore, choice B is not the correct answer.
Choice C rationale:
Lethargy may be seen in a child with appendicitis, especially if they are experiencing pain and discomfort. However, it is not a specific indicator of a perforated appendix. Lethargy can result from various factors, including pain and illness, but it does not directly correlate with perforation. Therefore, choice C is not the correct answer.
Choice D rationale:
Decreased abdominal girth is a concerning sign that can be indicative of a perforated appendix. When the appendix perforates, it can release infected material into the abdominal cavity, leading to inflammation and the formation of an abscess. This can cause the abdomen to become distended initially, but as the infection spreads and fluid accumulates in the abdominal cavity, the abdomen may appear swollen and then gradually decrease in girth as the abscess forms. Therefore, choice D is the correct answer as it reflects a significant and specific manifestation of a perforated appendix that requires prompt reporting to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A. Notify the charge nurse about the situation.
Choice A rationale: This is the correct answer because the nurse should notify the charge nurse or the provider who is responsible for obtaining informed consent from the client. The nurse cannot obtain informed consent from a client who does not understand the purpose, risks, benefits, and alternatives of the procedure. The nurse should also respect the client’s right to refuse or withdraw consent at any time. By notifying the charge nurse or the provider, the nurse ensures that the client receives adequate information and clarification before giving consent.This is consistent with the ethical and legal principles of informed consent in nursing
Choice B rationale: This is incorrect because the nurse should not ask the client to sign the consent form anyway. This would violate the client’s autonomy and right to make informed decisions about their health. It would also expose the nurse and the provider to legal and ethical consequences for performing a procedure without valid consent. The nurse should ensure that the client understands the information provided and agrees to the procedure voluntarily. Asking the client to sign the consent form anyway would undermine the trust and communication between the client and the healthcare team.
Choice C rationale: This is incorrect because the nurse should not explain to the client that the procedure will help treat his diagnosis. This is not the nurse’s role or responsibility in the process of obtaining informed consent. The nurse should not provide information that is beyond their scope of practice or expertise. The nurse should also not persuade or coerce the client to agree to the procedure. The nurse should refer the client to the provider who can explain the rationale and evidence for the procedure and answer any questions or concerns the client may have.
Choice D rationale: This is incorrect because the nurse should not remind the client about the specifics of the procedure. This is not the nurse’s role or responsibility in the process of obtaining informed consent. The nurse should not repeat or restate information that the provider has already given to the client. The nurse should also not assume that the client has forgotten or misunderstood the information. The nurse should respect the client’s right to ask questions and seek clarification from the provider who can provide accurate and comprehensive information about the procedure.
Correct Answer is C
Explanation
Choice A rationale:
Carrying the baby to the nursery may not align with facility security measures. Typically, hospitals have strict protocols for baby transport within the facility, including the use of identification bands.
Choice B rationale:
Taking the baby to the lobby to visit family may also not be in line with security measures. Visitors should typically come to the designated patient areas rather than taking the baby to the lobby.
Choice C rationale:
Having an identification band that matches the one the baby wears is the correct understanding of facility security measures. This ensures proper identification of the baby and helps prevent infant abduction or mix-ups.
Choice D rationale:
Removing the security band to give it to a family member is not in line with security measures. The baby's identification band should remain intact at all times to ensure proper identification and security.
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