A nurse is caring for a school-age child who has appendicitis.
For which of the following findings should the nurse monitor as a manifestation of a perforated appendix and report to the provider?

Bradycardia.

Elevated temperature.

Lethargy.

Decreased abdominal girth.

Answer and Explanation

The Correct Answer is B

The correct answer is Choice B.

Choice A rationale: Bradycardia is not typically associated with a perforated appendix. Instead, tachycardia (increased heart rate) may occur due to pain and infection-related systemic responses. Bradycardia could indicate other unrelated medical issues and should still be monitored.

Choice B rationale: Elevated temperature is a key sign of infection and inflammation, which are common with a perforated appendix. The release of bacteria into the abdominal cavity can cause peritonitis, leading to fever as part of the body's immune response.

Choice C rationale: Lethargy can be a nonspecific symptom and may occur in various conditions. While it can be associated with severe infection, it is not a definitive indicator of a perforated appendix. Monitoring for more specific signs, like fever and pain, is crucial.

Choice D rationale: Decreased abdominal girth is unlikely and not indicative of a perforated appendix. Instead, an increase in abdominal girth due to fluid accumulation (ascites) or air (from perforation) would be more concerning and should be reported promptly.

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Correct Answer is C

Explanation

The correct answer is: c. A client who exhibits an increase in energy.

Choice A reason: A client with psychomotor retardation may experience a visible slowing of physical and emotional reactions. This symptom is associated with major depressive disorder and can manifest as slowed speech, decreased movement, and impaired cognitive function. While psychomotor retardation is a significant symptom of depression, it is not typically identified as the highest risk factor for suicide when compared to other symptoms such as a sudden increase in energy, which can indicate a potential for acting on suicidal thoughts.

Choice B reason: An inability to concentrate is another symptom that can be present in individuals with major depressive disorder. It refers to difficulty in focusing, making decisions, or remembering things. Although this can contribute to the overall severity of depression, it is not directly linked to an increased risk of suicide as strongly as some other symptoms like changes in sleep patterns or behavior.

Choice C reason: An increase in energy in a client with major depressive disorder, especially if it occurs suddenly, can be a warning sign of potential suicidal behavior. This change can indicate that the individual has decided about suicide and may now have the energy to act on these thoughts. It is important for healthcare providers to closely monitor such changes in energy levels, as they can be indicative of an increased risk for suicide.

Choice D reason: Persistent insomnia is a common symptom in individuals with major depressive disorder and can exacerbate other symptoms of depression. Lack of sleep can lead to irritability, cognitive impairment, and can affect overall health. While it is a concerning symptom and can affect a person’s risk for suicide, it is not considered the single highest risk factor when compared to a sudden increase in energy.

A. Encourage the client to have continual bed rest. B. Encourage strength-training exercise. C. Increase the client's fluids to 4 L per day. D. Increase protein in the diet.

Correct Answer is B

Explanation

Choice A rationale:

Encourage the client to have continual bed rest. Rationale: Continual bed rest is not the appropriate intervention for a client experiencing chronic fatigue due to leukemia. Prolonged bed rest can lead to further weakness and deconditioning. Encouraging some level of physical activity, such as gentle exercise, can help improve strength and reduce fatigue.

Choice B rationale:

Encourage strength-training exercise. Rationale: This is the correct intervention for a client with leukemia experiencing chronic fatigue. Strength-training exercises, when appropriate and under the guidance of healthcare professionals, can help improve muscle strength and overall endurance. It can combat the fatigue commonly associated with leukemia and its treatment.

Choice C rationale:

Increase the client's fluids to 4 L per day. Rationale: While adequate hydration is essential, increasing fluids to 4 liters per day may not be appropriate for every client. The optimal fluid intake for a client should be determined based on their individual needs and medical condition. Excessive fluid intake without medical indication can lead to complications like fluid overload.

Choice D rationale:

Increase protein in the diet. Rationale: Increasing protein intake can be beneficial for clients with leukemia as it helps in tissue repair and supports the immune system. However, it should be done in consultation with a registered dietitian to ensure that the client's specific dietary needs are met.

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A nurse is caring for a school-age child who has appendicitis. For which of the following findings should the nurse monitor as a manifestation of a perforated appendix and report to the provider?

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a school-age child who has appendicitis.
For which of the following findings should the nurse monitor as a manifestation of a perforated appendix and report to the provider?