A nurse is caring for an adolescent who is 1 hr. postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
Muscle rigidity
Abdominal pain
Heart rate 63/min
Temperature 36.4° C (97.5" F)
The Correct Answer is A
Choice A Reason:
Muscle rigidity is correct. Muscle rigidity can indicate several concerning issues postoperatively, such as complications from anesthesia, infection, or other underlying problems. It's crucial to report this finding promptly to the provider for further evaluation and appropriate management.
Choice B Reason:
Some degree of abdominal pain is expected post-appendectomy, but the severity and persistence of the pain should be assessed further.
Choice C Reason:
Heart rate of 63/min is within the normal range for some adolescents and might not be an immediate concern unless there are other accompanying symptoms.
Choice D Reason:
A temperature of 36.4°C (97.5°F) falls within the normal range for body temperature and might not be a cause for immediate concern unless it's accompanied by other symptoms or if there are signs of temperature changes (like fever) over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Type 1 diabetes mellitus is correct. Type 1 diabetes is considered a risk factor for cardiovascular disease due to its potential impact on blood vessels and the heart over time. Individuals with diabetes, especially poorly controlled diabetes, are at a higher risk of developing cardiovascular complications such as heart disease, stroke, and peripheral vascular disease.
Choice B Reason:
Orthostatic hypotension is incorrect. Orthostatic hypotension refers to a drop-in blood pressure when moving from a lying or sitting position to a standing position. While it can cause symptoms like dizziness or lightheadedness, it's not typically considered a direct risk factor for cardiovascular disease. However, it might be associated with other conditions or medications that could contribute to cardiovascular issues indirectly.
Choice C Reason:
BMI of 24 is incorrect. A BMI (Body Mass Index) of 24 falls within the normal weight range. While obesity (especially central obesity or higher BMIs) is a known risk factor for cardiovascular disease, having a BMI of 24 by itself is not considered a significant risk factor for developing cardiovascular issues.
Choice D Reason:
Family history of osteoporosis is incorrect. Osteoporosis is a condition characterized by weakened bones, not directly related to cardiovascular disease. A family history of osteoporosis doesn't inherently indicate an increased risk of cardiovascular disease unless there are other associated factors or conditions within the family history that contribute to cardiovascular issues.
Correct Answer is A
Explanation
Choice A Reason:
Continuous swallowing is correct. Continuous swallowing can be an indication of postoperative bleeding after a tonsillectomy and adenoidectomy. Increased swallowing may suggest blood trickling down the throat, prompting the child to swallow frequently. It's an important sign to observe for and could indicate a risk of hemorrhage.
Choice B Reason:
Heart rate 54/min. While a low heart rate (bradycardia) might be a concern in some cases, it's not a typical sign of hemorrhage after this specific surgery.
Choice C Reason:
Blood pressure 95/56 mm Hg. While a drop-in blood pressure could be concerning for hemorrhage, this blood pressure reading alone may not necessarily indicate postoperative bleeding. Monitoring trends and other signs are important for a comprehensive assessment.
Choice D Reason:
Flushing of the face. Facial flushing is not typically associated with hemorrhage after a tonsillectomy and adenoidectomy. It might be related to other factors but is not a specific indicator of bleeding following this surgery.
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