A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect?
Bradycardia
Hyperactive bowel sounds
WBC 17,000/mm
Left lower quadrant abdominal pain
The Correct Answer is C
Choice A rationale
Bradycardia, or a slower than normal heart rate, is not typically associated with acute appendicitis. In fact, tachycardia, or a faster than normal heart rate, may occur due to the body’s response to inflammation and infection.
Choice B rationale
Hyperactive bowel sounds are not a typical finding in acute appendicitis. In fact, bowel sounds may be normal or decreased due to the inflammatory process.
Choice C rationale
A white blood cell (WBC) count of 17,000/mm is higher than the normal range, indicating the presence of an infection or inflammation in the body. This is a common finding in acute appendicitis.
Choice D rationale
Pain from appendicitis is typically located in the right lower quadrant of the abdomen, not the left.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis.
Choice B rationale
Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant’s lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant’s weight and frequency of vomiting to assess the infant’s progress.
Choice C rationale
Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea.
However, the symptoms described by the parents do not align with this condition.
Choice D rationale
Milk Protein Allergy in infants is a condition where the infant’s immune system reacts negatively to the proteins in cow’s milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.
Correct Answer is B
Explanation
Choice A rationale:
Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped mass in the upper abdomen, and signs of dehydration.
Choice B rationale:
A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting. The infant may appear hungry after vomiting and will continue to feed, leading to weight loss.
Choice C rationale:
Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible peristalsis occurs as the infant tries to force the stomach contents through the narrowed pyloric sphincter. Weight loss is a result of poor feeding and vomiting.
Choice D rationale:
Distention of the lower abdomen and constipation are not typical findings in pyloric stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis primarily affects the upper gastrointestinal tract.
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