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 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.

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Correct Answer is B

Explanation

Choice A rationale:

Cleansing the skin with an antibacterial soap is not typically recommended for clients with systemic lupus erythematosus (SLE) unless there is a specific medical indication for antibacterial soap. Using mild, non-irritating, hypoallergenic soap is usually preferred to avoid skin irritation in individuals with SLE.

Choice B rationale:

This is the correct answer. Patting the skin dry with a towel instead of rubbing it helps to prevent excessive friction and irritation, which can be particularly important for individuals with SLE who may have sensitive skin. The client demonstrates an understanding of appropriate skin care by choosing this option.

Choice C rationale:

Using an astringent on the face is generally discouraged for individuals with SLE. Astringents can be harsh and may irritate the skin, which can exacerbate skin problems commonly associated with SLE. This statement indicates a misunderstanding of appropriate skin care.

Choice D rationale:

Limiting time in the tanning bed is advisable for anyone, as excessive exposure to UV radiation can increase the risk of skin damage and skin cancers. However, individuals with SLE are especially sensitive to UV radiation, and they should avoid tanning beds altogether. This statement indicates a lack of understanding of the specific needs of individuals with SLE regarding sun exposure.

A. Wash hands with soap and water for 20 seconds. B. Wear sterile gloves when in contact with body fluids. C. Use alcohol-based cleanser when hands are visibly soiled. D. Artificial nails can be worn when performing direct client care.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should include the instruction to wash hands with soap and water for 20 seconds in the teaching. This is a fundamental aspect of hand hygiene in healthcare settings. The rationale for this choice is that proper handwashing with soap and water for at least 20 seconds is the most effective way to remove dirt, debris, and transient microorganisms from the hands. It helps prevent the spread of infections, including those caused by viruses and bacteria.

Choice B rationale:

Wearing sterile gloves when in contact with body fluids is not directly related to hand hygiene education. While wearing gloves is an essential infection control practice, it is not a substitute for proper handwashing. Hand hygiene should be performed before donning gloves and after removing them.

Choice C rationale:

Using alcohol-based cleanser when hands are visibly soiled is not the best instruction for hand hygiene. Alcohol-based hand sanitizers are effective when hands are not visibly soiled. In cases of visible soiling, handwashing with soap and water is recommended to physically remove dirt and contaminants.

Choice D rationale:

Artificial nails should not be worn when performing direct client care as they can harbor microorganisms and make it challenging to clean the hands adequately. The use of artificial nails can increase the risk of transmitting infections to patients, which is why they should be discouraged in healthcare settings.

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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?