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
Choice A rationale:
The nurse's first action when caring for a client with bulimia nervosa should be to observe the client during and after meals. This is essential to monitor for signs of binge-eating followed by compensatory behaviors such as vomiting or the misuse of laxatives. Timely observation can help ensure the client's safety and provide an opportunity for immediate intervention if necessary.
Choice B rationale:
Suggesting that the client assist with meal planning can be a beneficial intervention, but it should not be the first action. Clients with bulimia nervosa often have complex emotional and psychological issues related to their eating habits, so it's crucial to address the immediate risks of binge-purge episodes before moving on to meal planning.
Choice C rationale:
Instructing the client about effective coping strategies is important for long-term recovery, but it should not be the first action. Immediate safety concerns, such as monitoring for binge-purge behaviors, take precedence in the initial care of a client with bulimia nervosa.
Choice D rationale:
Referring the client to a support group is a valuable intervention in the long-term management of bulimia nervosa, but it should not be the first action. The immediate priority is to assess and address any acute risks associated with the disorder, such as binge-purge episodes.
Correct Answer is D
Explanation
Choice A rationale:
Allowing the patient to lift the CPM machine onto the bed is not a safe practice. Arthroscopic surgery may result in limited mobility and discomfort for the patient. Lifting heavy equipment could potentially strain the surgical site or lead to injury.
Choice B rationale:
Telling the patient that CPM will not hurt at all is not accurate. While CPM is a passive motion technique aimed at preventing joint stiffness, some discomfort or mild pain may be experienced, especially during the initial sessions. Managing the patient's pain is essential to ensure compliance with the CPM exercises.
Choice C rationale:
Suggesting that the patient does not need to do CPM exercises is incorrect. CPM exercises are often prescribed after joint surgery to prevent joint stiffness, improve circulation, and aid in recovery. Discouraging the patient from participating in these exercises would be detrimental to their postoperative outcome.
Choice D rationale:
Administering an opioid analgesic to the client 30 minutes before initiating CPM exercises is the correct choice. CPM exercises can be uncomfortable for some patients, especially in the initial stages, and providing adequate pain relief before starting the exercises promotes patient comfort and compliance. It helps ensure that the patient can perform the exercises effectively without undue pain, reducing the risk of complications and promoting a successful recovery.
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