A 9-year-old admitted to the unit with severe abdominal pain and fever is diagnosed with appendicitis and is placed on the surgery schedule for an appendectomy. The child reports to the nurse of experiencing sudden relief in abdominal pain. Which action should the nurse take first?
Document the client's relief of pain.
Inquire about the client's last meal.
Give prescribed intravenous antibiotics.
Contact the healthcare provider.
The Correct Answer is D
A. Documenting the client's relief of pain is important for the medical record but is not the first priority in this situation. The immediate concern is to determine the cause of the sudden pain relief and ensure the child's well-being.
B. Inquiring about the client's last meal is important for pre-operative considerations, but it is not the first action to take when sudden relief of abdominal pain is reported.
C. Giving prescribed intravenous antibiotics may be part of the treatment plan, but it should not be the first action when the child experiences sudden relief of abdominal pain. Contacting the healthcare provider to assess the situation is more urgent.
D Contact the healthcare provider.
In the case of a child diagnosed with appendicitis, sudden relief in abdominal pain can be concerning. This might indicate that the appendix has ruptured, leading to the spread of infection into the abdominal cavity, which can be a critical situation. It's essential for the healthcare provider to be informed immediately so they can assess the child's condition, order any necessary interventions, and potentially expedite the surgical procedure if required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Comparing the child's vital signs over the past three weeks (option A) may not provide significant information about the underlying cause of his symptoms, as vital signs are unlikely to directly indicate stress or emotional distress.
B. Counseling the parents to pay more attention to the child (option B) is a general suggestion and may not be the most effective way to address the specific issues he is facing. It's important to identify the underlying causes and stressors first.
C. Conducting a complete neurological assessment (option C) is not warranted at this stage, as the child's symptoms are more likely related to emotional or psychological factors rather than a neurological problem. Gathering information about his school experiences would be a more appropriate initial step.
D. Ask the boy to describe a typical day at school.
The child's reported symptoms, including headaches, stomach aches, and difficulty sleeping, may be indicative of stress or emotional issues. To better understand and address the underlying cause of these symptoms, it's important to gather more information about the child's daily experiences. By asking the boy to describe a typical day at school (option D), the nurse can uncover potential stressors or challenges he may be facing, such as academic difficulties, bullying, social issues, or other stressors that might be contributing to his symptoms.
Correct Answer is B
Explanation
A. Collecting a sterile urine sample for culture and sensitivity is not the priority in this situation. The primary concern is the potential testicular torsion, and this action does not address that concern.
B Report the findings immediately to the healthcare provider.
Intense pain in the testicular area, especially when accompanied by significant erythema (redness) and swelling, can be indicative of a serious condition such as testicular torsion, which is a medical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off blood supply to the testicle. It requires immediate medical evaluation and intervention.
C. Obtaining a swab of secretions from the penis and urethra is not the most immediate concern in the presence of intense testicular pain, erythema, and swelling. It may be relevant for other conditions but does not address the urgency of this situation.
D. Providing the adolescent with a urinal for urinary hesitancy does not address the primary concern, which is the possibility of testicular torsion. Testicular torsion is not related to urinary hesitancy.
Testicular torsion is a surgical emergency, and the healthcare provider should be notified immediately to evaluate the adolescent and initiate appropriate treatment. Delay in diagnosis and intervention can lead to testicular damage and potential loss of the affected testicle.
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