A nurse in an emergency department is caring for a client who has suspected appendicitis. Which of the following actions should the nurse plan to take?

Monitor the client for an elevated RBC count.

Instruct the client to not eat food or drink liquids.

Administer an enema to the client.

Maintain the client in a supine position.

Answer and Explanation

The Correct Answer is B

A. Monitor the client for an elevated RBC count.: While an elevated white blood cell count (WBC) is more indicative of appendicitis, an elevated RBC count is not typically used to diagnose appendicitis.

B. Instruct the client to not eat food or drink liquids.: This is important as it prepares the client for a potential surgical procedure. If the appendix is inflamed and surgery is necessary, the client should not eat or drink to prevent complications related to anesthesia and surgery.

C. Administer an enema to the client.: Administering an enema is not recommended as it can increase the risk of perforation of the appendix, which is a serious complication.

D. Maintain the client in a supine position.: While maintaining a supine position may be necessary, it is not as critical as ensuring the client remains NPO (nil per os) in preparation for possible surgery. The position is less of a priority compared to dietary restrictions in this scenario.

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Correct Answer is B

Explanation

A) "A parent is supposed to pass before their child": This statement reflects ongoing grief and a struggle with the loss, indicating the client is still grappling with the emotional impact rather than moving toward reorganization and acceptance.

B) "My partner and I have plans to open a small business": This statement demonstrates that the client is beginning to focus on future goals and engaging in activities that signify a return to normalcy and investment in life. This reflects reorganization and acceptance of the loss as they are planning for the future.

C) "I have put all the pictures of my child in the attic": Putting away pictures of the child might indicate avoidance or difficulty coping with reminders of the loss. This action suggests the client may still be in the process of dealing with grief rather than having reached acceptance.

D) "My partner says I seem to forget things frequently": Frequent forgetfulness can be a symptom of ongoing grief and emotional distress. This indicates that the client may still be experiencing significant emotional and cognitive impacts from the loss.

A. Weight gain B. Warm extremities after walking C. Breathlessness when carrying an object D. Increased urinary output during the day

Correct Answer is C

Explanation

A) Weight gain: Weight gain is more commonly associated with right-sided heart failure due to fluid retention and peripheral edema. While left-sided heart failure can lead to overall heart failure, causing weight gain, it is not as specific as breathlessness for left-sided failure.

B) Warm extremities after walking: Warm extremities are generally a sign of good circulation. In clients with left-sided heart failure, reduced cardiac output often leads to poor peripheral circulation, which would more likely cause cool extremities.

C) Breathlessness when carrying an object: Left-sided heart failure leads to decreased cardiac output and pulmonary congestion. As a result, clients often experience breathlessness or dyspnea, especially during physical activities, because the heart cannot efficiently pump blood, leading to fluid buildup in the lungs.

D) Increased urinary output during the day: Left-sided heart failure usually causes decreased renal perfusion, leading to reduced urinary output during the day. Clients might experience nocturia (increased nighttime urination) due to fluid reabsorption when lying down, but increased daytime output is not typical.

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A nurse in an emergency department is caring for a client who has suspected appendicitis. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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