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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
When a nurse notes the presence of bruises on a child’s arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
Choice A rationale
Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities.
Choice B rationale
Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse.
Choice C rationale
Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities.
Correct Answer is A
Explanation
Choice A rationale
Pediculosis capitis, also known as head lice, is a common condition in children. One of the definitive indications of this condition is the presence of firmly attached white particles on the hair, which are the eggs or “nits” of the lice.
Choice B rationale
While itching and scratching of the head can be a symptom of pediculosis capitis, it is not a definitive indication as it can be caused by other conditions such as dandruff or dermatitis.
Choice C rationale
Patchy areas of hair loss are not typically associated with pediculosis capitis. They could indicate a different condition, such as alopecia areata or tinea capitis.
Choice D rationale
Thick yellow-crusted lesions on a red base are not a symptom of pediculosis capitis. This description is more consistent with impetigo, a bacterial skin infection.
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