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 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.
Correct Answer is A
Explanation
Choice A reason: Intravenous immunoglobulin (IVIG) is the main treatment for Kawasaki disease, as it reduces the inflammation of the blood vessels and the risk of coronary artery aneurysms. IVIG is given as a single infusion over 10 to 12 hours, within the first 10 days of the onset of fever.
Choice B reason: Aspirin is also used to treat Kawasaki disease, as it reduces the fever, pain, and inflammation. However, it is not the first-line treatment, and it is given after IVIG to prevent thrombosis and platelet aggregation. Aspirin is given at a high dose during the acute phase, and then at a low dose until the inflammation subsides.
Choice C reason: Penicillin is not indicated for Kawasaki disease, as it is an antibiotic that treats bacterial infections. Kawasaki disease is not caused by bacteria, but by an unknown trigger that activates the immune system and causes systemic vasculitis.
Choice D reason: Acetaminophen is not effective for Kawasaki disease, as it does not reduce the inflammation or the risk of complications. Acetaminophen may be used to treat mild pain or fever, but it is not the main treatment. Moreover, acetaminophen may mask the fever and delay the diagnosis of Kawasaki disease.
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