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 D
Explanation
Choice A reason: Increased appetite is not a common finding in children with brain tumors. On the contrary, they may have decreased appetite, nausea, vomiting, or weight loss due to increased intracranial pressure or tumor location.
Choice B reason: Negative Babinski reflex is a normal finding in children over 2 years old and adults. It means that the toes curl downward when the sole of the foot is stimulated. A positive Babinski reflex, which means that the big toe moves upward and the other toes fan outward, is a sign of damage to the corticospinal tract, which may be caused by a brain tumor.
Choice C reason: Tachycardia, or rapid heart rate, is not a specific finding for brain tumors. It may be caused by many factors, such as fever, pain, anxiety, dehydration, or medications. However, some brain tumors may affect the autonomic nervous system, which regulates the heart rate, and cause bradycardia, or slow heart rate.
Choice D reason: Hyporeflexia, or diminished reflexes, is a possible finding in children with brain tumors. It indicates a dysfunction of the lower motor neurons, which may be affected by the tumor or the increased intracranial pressure. Hyporeflexia may manifest as weakness, numbness, or decreased muscle tone in the affected limbs.
Correct Answer is B
Explanation
Choice A reason: Pyloric stenosis is not a manifestation of inadequate motility of part of the intestine, but rather a hypertrophy of the pyloric muscle, which causes gastric outlet obstruction and delayed gastric emptying. Pyloric stenosis typically presents with projectile vomiting, dehydration, weight loss, and a palpable olive-shaped mass in the abdomen.
Choice B reason: Hirschsprung's disease is a manifestation of inadequate motility of part of the intestine, as it is caused by the absence of ganglion cells in the distal colon, which results in a lack of peristalsis and a functional obstruction. Hirschsprung's disease typically presents with constipation, abdominal distension, failure to thrive, and enterocolitis.
Choice C reason: Encopresis is not a manifestation of inadequate motility of part of the intestine, but rather a condition in which a child over 4 years of age involuntarily passes stool, usually due to chronic constipation and fecal impaction. Encopresis typically presents with soiling of the underwear, abdominal pain, low self-esteem, and behavioral problems.
Choice D reason: Enterocolitis is not a manifestation of inadequate motility of part of the intestine, but rather an inflammation of the mucosa of the small and large intestines, which can be caused by various infections, allergies, or ischemia. Enterocolitis typically presents with diarrhea, fever, abdominal pain, and dehydration.
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