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 C
Explanation
Choice A rationale
While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice B rationale
A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice C rationale
This is the correct answer. Checking the child’s weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions.
Choice D rationale
Educating the parents about potential complications is important, but it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Correct Answer is A
Explanation
Choice A rationale
Bending forward from the waist with the head and arms downward, also known as the Adams forward bend test, is the standard screening test for scoliosis.
Choice B rationale
Touching the chin to the chest and then looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening.
Choice C rationale
Lying prone on the examination table is not a standard position for scoliosis screening.
Choice D rationale
Turning to the side and remaining in a relaxed position is not a standard position for scoliosis screening.
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