A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?
"My belly doesn't hurt anymore."
"I am hungry and thirsty."
"I'm tired and want to take a nap."
"I am scared and I want to go home."
The Correct Answer is A
A. "My belly doesn't hurt anymore."
- This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.
B. "I am hungry and thirsty."
- While it's normal for a child to feel hungry and thirsty, especially if they have been experiencing nausea and vomiting, this statement is not necessarily concerning on its own. However, in the context of suspected appendicitis and severe right lower quadrant pain, it's important for the child to remain NPO (nothing by mouth) to prevent complications in case surgery is needed.
C. "I'm tired and want to take a nap."
- Feeling tired and wanting to rest is not uncommon, especially if the child has been experiencing discomfort or pain for a prolonged period. While this statement may indicate fatigue, it's not inherently concerning in the context of suspected appendicitis. However, it's important for the nurse to monitor the child's energy level and overall condition.
D. "I am scared and I want to go home."
- It's understandable for a child to feel scared or anxious, particularly when facing a medical procedure such as surgery. While this statement reflects the child's emotions, it doesn't necessarily indicate a change in their medical condition. However, it's important for the nurse to address the child's fears and provide emotional support while ensuring that the child receives appropriate medical care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pain management is critical for burn care, especially before activities like physical therapy that can be painful. Administering pain medication 30 minutes before therapy helps ensure the child is more comfortable and able to participate effectively in rehabilitation. This is a recommended intervention.
B. While involving the child in decisions about their care can promote autonomy and improve adherence, the schedule for burn care and therapy should be based on medical needs and healing processes rather than the child's preference. Care schedules should be designed to optimize healing and manage pain effectively.
C. Provide low-calorie snacks:Burn patients typically have increased nutritional needs due to the high metabolic demands of healing. High-calorie, protein-rich snacks are usually recommended to support wound healing and overall recovery, rather than low-calorie options.
D. Maintain medical asepsis during dressing changes: For burn care, maintaining sterile technique is critical to prevent infection. Medical asepsis is generally not sufficient; sterile technique is required for dressing changes to reduce the risk of infection.
Correct Answer is ["C","D"]
Explanation
A. Place a tongue depressor in the child's mouth: This is an incorrect action. Placing a tongue depressor or any other object in the child's mouth during a seizure can cause injury to the child's mouth, teeth, or airway. It may also increase the risk of choking. It's a common misconception that people can swallow their tongues during a seizure, but this is not true. It's important to keep the child's mouth clear of objects and allow the seizure to run its course.
B. Restrain the child: This is also an incorrect action. Restraint can cause further injury to the child and increase agitation, which may worsen the seizure. It's important to allow the child to move freely during a seizure while taking steps to ensure their safety, such as clearing the area of objects and protecting the head from injury.
C. Clear the area of hard objects: This is a correct action. Removing hard objects from the area helps prevent injury to the child during a seizure. Objects such as furniture corners or sharp items can pose a risk if the child thrashes or moves unpredictably during the seizure.
D. Loosen restrictive clothing: This is also a correct action. During a seizure, it's important to ensure that the child's clothing is not too tight or restrictive. Loosening clothing, especially around the neck and chest area, helps ensure adequate airflow and prevents restriction of movement during the seizure.
E. Place the child in a prone position: This is an incorrect action. Placing the child in a prone (face-down) position during a seizure can increase the risk of airway obstruction and make it more difficult for the child to breathe. Instead, the child should be placed on their side (recovery position) to help maintain an open airway and prevent aspiration if vomiting occurs.
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