A nurse is collecting data from a client who has suspected appendicitis. What finding should the nurse prioritize to report to the provider?
Loss of appetite
WBC count 15,000/mm
Rigid, board-like abdomen
Temperature 37.8°C (100°F)
The Correct Answer is C
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D, Describe the food placement as though the plate were a clock. When delivering the client's meal tray, the nurse should describe the food placement as though the plate were a clock to help the client know where the food is located. This helps the client be more independent and participate actively at mealtime. Choice A is incorrect because arranging for assistive personnel to feed the client may take away the client's independence. Choice B is incorrect because discouraging conversations during the client's mealtime may make the client feel isolated. Choice C is incorrect because providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
Other choices:
A. Arrange for assistive personnel to feed the client: Arranging for assistive personnel to feed the client may take away the client's independence.
B. Discourage conversations during the client's mealtime: Discouraging conversations during the client's mealtime may make the client feel isolated.
B. Provide the client with small-handled adaptive utensils: Providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
Correct Answer is D
Explanation
Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.
The other choices are not correct because:
- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.
- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.
- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.
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