When caring for a child with probable appendicitis, the nurse would be alert to recognize which condition or symptom is a sign of perforation?
Decreased abdominal distention
Anorexia
Bradycardia
Sudden relief from pain
The Correct Answer is D
Choice A reason:
Decreased abdominal distention is not typically a sign of appendicitis perforation. In fact, perforation often leads to increased abdominal distention due to the release of intestinal contents into the abdominal cavity, causing inflammation and swelling. Therefore, this choice is incorrect.
Choice B reason:
Anorexia, or loss of appetite, is a common symptom of appendicitis but not specifically indicative of perforation2. While anorexia can be present in cases of perforation, it is not a definitive sign. The sudden relief of pain is a more critical indicator of perforation, as it suggests the appendix has ruptured, temporarily relieving pressure.
Choice C reason:
Bradycardia, or a slow heart rate, is not a typical sign of appendicitis perforation. In fact, appendicitis and its complications, such as perforation, are more likely to cause tachycardia (an increased heart rate) due to pain and infection. Therefore, this choice is incorrect.
Choice D reason:
Sudden relief from pain is a classic sign of appendicitis perforation. When the appendix ruptures, the pressure inside the appendix is relieved, leading to a temporary decrease in pain. However, this is followed by a rapid onset of severe pain as the contents of the appendix spread throughout the abdominal cavity, causing peritonitis. This sudden change in pain is a critical indicator that the appendix has perforated and requires immediate medical attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Foster self-care activities: Encouraging self-care activities is important for children with hemiplegic cerebral palsy as it promotes independence and self-esteem. However, it is not the highest priority compared to ensuring the child’s safety and accessibility in their home environment.
Choice B Reason:
Improve the child’s communication skills: Enhancing communication skills is crucial for the child’s social and emotional development. Effective communication can significantly improve the child’s quality of life. However, while important, it is not the most immediate priority compared to modifying the home environment for safety.
Choice C Reason:
Modify the home environment for safety and accessibility: Ensuring the home environment is safe and accessible is the top priority. Children with hemiplegic cerebral palsy may have mobility challenges, and a safe environment can prevent injuries and promote independence. This modification directly impacts the child’s daily life and overall well-being.
Choice D Reason:
Provide respite services for the parents: Offering respite services is beneficial for the parents’ mental and emotional health, allowing them to take breaks and recharge. While this is important, it is not the primary concern compared to the child’s immediate safety and accessibility needs.
Correct Answer is C
Explanation
Choice A reason:
Measuring the abdominal girth is a useful assessment tool in cases of suspected abdominal distension or fluid accumulation. However, in the context of intussusception, the passage of a currant jelly-like stool is a more critical indicator of the condition. While measuring abdominal girth can provide additional information, it is not the most appropriate immediate action in this scenario.
Choice B reason:
Notifying the practitioner as this is not a typical finding is incorrect because the passage of currant jelly-like stool is a classic symptom of intussusception. This stool appearance results from a mixture of mucus and blood due to the telescoping of the intestine, which compromises blood flow and causes ischemia. Therefore, this finding should be documented as expected rather than considered atypical.
Choice C reason:
Documenting the passage of currant jelly-like stool as an expected finding and planning to move forward with the procedure is the most appropriate action. This stool appearance is a hallmark sign of intussusception, indicating that the condition is present and needs to be addressed promptly. The radiologist-guided pneumoenema is a diagnostic and therapeutic procedure that can help resolve the intussusception by using air pressure to unfold the telescoped segment of the intestine. Therefore, documenting this finding and proceeding with the planned intervention is crucial.
Choice D reason:
Auscultating for bowel sounds is a standard nursing assessment technique to evaluate gastrointestinal function. However, in the context of intussusception, the passage of currant jelly-like stool is a more definitive indicator of the condition. While auscultating for bowel sounds can provide additional information about bowel activity, it is not the most appropriate immediate action in this scenario.
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