A nurse is assessing a child diagnosed with appendicitis.
Which finding requires immediate intervention?
High elevation in white blood cell count.
Guarding and rebound tenderness.
Sudden relief of pain followed by rigid abdomen and fever.
Abdominal tenderness in the right lower quadrant.
The Correct Answer is C
Choice A rationale
A high elevation in the white blood cell count, or leukocytosis, is an expected inflammatory response in appendicitis. While an elevated WBC count (normal range typically 4,500 to 11,000 cells/mcL) indicates infection or inflammation, it does not necessarily signal immediate, life-threatening complications requiring immediate intervention.
Choice B rationale
Guarding, which is the tensing of abdominal muscles upon palpation, and rebound tenderness, pain that worsens when pressure is released, are classic signs of peritoneal irritation associated with appendicitis. These findings suggest inflammation of the peritoneum but do not indicate an immediate, critical emergency in the same way as sudden pain relief.
Choice C rationale
Sudden relief of pain in a child with appendicitis, followed by a rigid abdomen and fever, is a critical sign of a ruptured appendix and subsequent peritonitis. The rupture releases the pressure causing the initial pain, but the spillage of bowel contents leads to widespread inflammation of the peritoneum, a serious and potentially life-threatening condition requiring immediate surgical intervention to prevent sepsis and other complications.
Choice D rationale
Abdominal tenderness in the right lower quadrant (RLQ), often referred to as McBurney's point, is a characteristic finding in appendicitis due to the inflammation of the appendix in this anatomical location. While it warrants investigation and treatment, localized tenderness alone does not indicate an immediate, life-threatening complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","G"]
Explanation
Choice A rationale
Nephrotic syndrome typically has a gradual onset of symptoms, developing over days to weeks, as protein loss in the urine accumulates. An abrupt onset is less characteristic.
Choice B rationale
Proteinuria, the presence of abnormally high levels of protein in the urine (normal range is less than 150 mg/24 hours), is a defining characteristic of nephrotic syndrome. Damage to the glomeruli in the kidneys leads to increased permeability and leakage of protein into the urine.
Choice C rationale
Hypoalbuminemia in the blood (normal range is 3.5 to 5.5 g/dL) is a key feature of nephrotic syndrome. The excessive loss of protein in the urine leads to a decrease in serum albumin levels.
Choice D rationale
Fever is not typically a primary symptom of nephrotic syndrome. While children with nephrotic syndrome can develop infections, fever is not a direct consequence of the underlying kidney dysfunction.
Choice E rationale
Hyperlipidemia, an elevated level of lipids (fats) in the blood (normal total cholesterol is less than 200 mg/dL), is commonly associated with nephrotic syndrome. The liver increases lipoprotein synthesis in response to the decreased serum albumin levels.
Choice F rationale
While a positive Group A beta-hemolytic streptococcal infection can lead to post-streptococcal glomerulonephritis, which can sometimes present with nephrotic features, it is not a common finding directly associated with the primary diagnosis of nephrotic syndrome itself.
Choice G rationale
Anasarca, which is severe generalized edema characterized by widespread swelling due to fluid retention, is a common finding in nephrotic syndrome. The low serum albumin levels reduce oncotic pressure in the blood vessels, leading to fluid shifting into the interstitial spaces. .
Correct Answer is A
Explanation
Choice A rationale
The industry vs inferiority stage, according to Erik Erikson's stages of psychosocial development, occurs during middle childhood (approximately 6 to 12 years). Children in this stage focus on mastering new skills and knowledge, developing a sense of competence and industry through activities like building models and participating in team sports. Success in these endeavors leads to a feeling of accomplishment, while failure can result in feelings of inferiority.
Choice B rationale
The initiative vs guilt stage occurs during the preschool years (approximately 3 to 5 years). Children in this stage are eager to take on new tasks and activities, developing a sense of initiative. However, if their efforts are met with criticism or failure, they may develop feelings of guilt.
Choice C rationale
The autonomy vs shame and doubt stage occurs during early childhood (approximately 18 months to 3 years). Children in this stage are focused on developing independence and self-control. Success in achieving autonomy leads to feelings of confidence, while failure can result in shame and doubt about their abilities.
Choice D rationale
The identity vs role confusion stage occurs during adolescence (approximately 12 to 18 years). During this stage, individuals are exploring their sense of self and trying to establish their identity in various aspects of life. Failure to establish a clear sense of identity can lead to role confusion.
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