A nurse is assessing a child who has appendicitis. Which of the following findings should the nurse expect?
Pain
High fever
Constipation
Bradycardia
The Correct Answer is A
Choice A reason: Pain is an expected finding for a child who has appendicitis, as it is caused by the inflammation and infection of the appendix, which is a small pouch attached to the cecum. Pain usually begins around the umbilicus and then shifts to the right lower quadrant, and it may worsen with movement, coughing, or deep breathing.
Choice B reason: High fever is not an expected finding for a child who has appendicitis, as it indicates a severe infection or a perforation of the appendix, which can lead to peritonitis or sepsis. A mild fever may be present in some cases of appendicitis, but it is not a specific or reliable sign.
Choice C reason: Constipation is not an expected finding for a child who has appendicitis, as it is not related to the function or location of the appendix. Constipation may be caused by many other factors, such as dehydration, diet, medication, or bowel habits. Diarrhea may occur in some cases of appendicitis, but it is also not a specific or reliable sign.
Choice D reason: Bradycardia is not an expected finding for a child who has appendicitis, as it indicates a decreased heart rate, which can be a sign of shock, hypothermia, or cardiac problems. Bradycardia is defined as a heart rate below 60/min in children older than 1 year, or below 100/min in infants younger than 1 year. Tachycardia, or an increased heart rate, may occur in some cases of appendicitis, as a result of pain, fever, or dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Bleeding precaution is indicated for a child who has leukemia and a critically low platelet count, as it reduces the risk of hemorrhage and injury. The nurse should monitor the child for signs of bleeding, such as petechiae, ecchymosis, epistaxis, hematuria, and melena. The nurse should also avoid invasive procedures, use soft-bristled toothbrushes, apply pressure to venipuncture sites, and administer platelet transfusions as prescribed.
Choice B reason: Droplet precaution is not indicated for a child who has leukemia and a critically low platelet count, unless the child has a respiratory infection that is transmitted by droplets. Droplet precaution involves wearing a mask when within 3 feet of the child, and placing the child in a private room or with a roommate who has the same infection.
Choice C reason: Neutropenic precaution is indicated for a child who has leukemia and a critically low neutrophil count, as it reduces the risk of infection and sepsis. Neutropenic precaution involves placing the child in a private room with positive pressure airflow, wearing gloves, gown, and mask when entering the room, and restricting visitors who are ill or immunocompromised.
Choice D reason: Contact precaution is not indicated for a child who has leukemia and a critically low platelet count, unless the child has a skin or wound infection that is transmitted by direct or indirect contact. Contact precaution involves wearing gloves and gown when entering the room, and placing the child in a private room or with a roommate who has the same infection.
Correct Answer is B
Explanation
Choice A reason: A 13% weight loss is not a finding of severe dehydration, but rather of moderate dehydration. Severe dehydration is characterized by a weight loss of more than 15%.
Choice B reason: A rapid pulse is a finding of severe dehydration, as the body tries to compensate for the fluid loss and maintain the blood pressure.
Choice C reason: A bulging anterior fontanel is not a finding of severe dehydration, but rather of increased intracranial pressure. A sunken anterior fontanel is a sign of severe dehydration, as the brain tissue loses water and shrinks.
Choice D reason: Moist mucous membranes are not a finding of severe dehydration, but rather of normal hydration. Dry mucous membranes are a sign of severe dehydration, as the body loses water and electrolytes.
Choice E reason: Decreased urine output is a finding of severe dehydration, as the kidneys try to conserve water and produce less urine. This can lead to renal failure if not corrected.
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