The nurse is caring for a client who presents with acute appendicitis:

Exhibits

Select all that apply?

Creatinine, 0.9 mg/dL

White blood cell count, 11,500 mm"

BUN 26 mg/dL.

Reports of pain increasing while coughing

Potassium 3.3 mEq/L

Nausea and vomiting

Answer and Explanation

Correct Answer : B,C,D,E

Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.

Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.

Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.

Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.

Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.

Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.

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Correct Answer is B

Explanation

Choice A rationale: While joint deformities are concerning in RA, the immediate attention would be required for an acute, red, hot, swollen joint which could indicate an active inflammatory process.
Choice B rationale: Redness, heat, and swelling in a joint are signs of an acute flare in rheumatoid arthritis and might require urgent intervention to manage the inflammation.
Choice C rationale: Puffy-looking areas behind the knee might indicate joint involvement but might not require immediate attention as much as an acutely inflamed joint.
Choice D rationale: Jaw pain while eating can be a symptom of TMJ involvement in RA, but an acutely inflamed joint would generally take precedence.

A. Provide thickened fluids with a straw. B. Listen to bilateral lung and bowel sounds. C. Check the client's Hypoglossal nerve and Vestibulocochlear cranial nerve function. D. Check the client's Glossopharyngeal nerve and Vagus cranial nerve function.

Correct Answer is D

Explanation

Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.

Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.

Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.

Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.

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The nurse is caring for a client who presents with acute appendicitis: Exhibits Select all that apply?

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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The nurse is caring for a client who presents with acute appendicitis:

Exhibits

Select all that apply?