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
Explanation
Choice A rationale
Pain is a common symptom in superficial and partial-thickness burns where nerve endings are still intact. While pain indicates tissue damage, the absence of pain in a burn area can signify deeper and more severe injury where nerve endings have been destroyed.
Choice B rationale
No pain with pale, leathery skin is a characteristic finding of a full-thickness (third-degree) burn. The destruction of nerve endings eliminates pain sensation, and the skin appears dry, leathery, and may be white, charred, or translucent due to damage to all skin layers and underlying tissue.
Choice C rationale
Mild erythema, or redness of the skin, is characteristic of a superficial (first-degree) burn, such as a sunburn. These burns involve only the epidermis and are typically painful and without blisters.
Choice D rationale
Blister formation is a hallmark of partial-thickness (second-degree) burns, which involve the epidermis and part of the dermis. These burns are typically painful and moist.
Correct Answer is B
Explanation
Choice A rationale
Citrus foods are acidic and can irritate the esophagus, potentially worsening reflux symptoms in children with gastroesophageal reflux disease (GERD). Increasing citrus intake is generally not recommended.
Choice B rationale
Fatty foods tend to delay gastric emptying, which can increase the risk and duration of reflux episodes. Decreasing the intake of fatty foods can help reduce GERD symptoms by allowing the stomach to empty more quickly.
Choice C rationale
Spicy foods can irritate the lining of the esophagus and exacerbate reflux symptoms in individuals with GERD. Encouraging the consumption of spicy foods is generally contraindicated.
Choice D rationale
Fiber promotes healthy digestion and typically does not worsen GERD symptoms. In some cases, adequate fiber intake can even be beneficial. Limiting fiber intake is not a standard dietary recommendation for children with GERD.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.