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 C
Explanation
Choice A reason: A child with Hirschsprung disease may require a temporary or permanent ostomy, depending on the extent of the bowel affected. The parent should be prepared for either outcome and not assume that the ostomy is only temporary.
Choice B reason: A child with Hirschsprung disease will not have normal bowel movements immediately after the surgery, as the bowel needs time to heal and adapt. The parent should be aware of the possible complications and follow-up care that the child will need.
Choice C reason: A child with Hirschsprung disease may need a feeding tube after the surgery to provide adequate nutrition and hydration while the bowel recovers. The parent should express interest in learning how to use and care for the feeding tube, as this indicates an understanding of the teaching.
Choice D reason: A child with Hirschsprung disease will not need a urinary catheter after the surgery, unless there is a specific indication for it. The parent should not confuse the feeding tube with the urinary catheter, as this indicates a lack of understanding of the teaching.
Correct Answer is C
Explanation
Choice A reason: Ridged abdomen is not an expected finding for an infant who has pyloric stenosis, as it indicates abdominal rigidity or guarding, which can be a sign of peritonitis or bowel obstruction. Pyloric stenosis is a narrowing of the pyloric sphincter, which causes gastric outlet obstruction and delayed gastric emptying.
Choice B reason: Red currant jelly stools are not an expected finding for an infant who has pyloric stenosis, as they indicate blood and mucus in the stools, which can be a sign of intussusception or necrotizing enterocolitis. Pyloric stenosis does not affect the lower gastrointestinal tract, and the infant may have constipation or dehydration due to vomiting.
Choice C reason: Projectile vomiting is an expected finding for an infant who has pyloric stenosis, as it occurs after feeding due to the increased pressure in the stomach and the inability to pass food into the duodenum. Projectile vomiting can cause weight loss, dehydration, electrolyte imbalance, and metabolic alkalosis.
Choice D reason: Distended neck veins are not an expected finding for an infant who has pyloric stenosis, as they indicate increased central venous pressure, which can be a sign of heart failure or superior vena cava syndrome. Pyloric stenosis does not affect the cardiovascular system, and the infant may have sunken fontanels or poor skin turgor due to dehydration.
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