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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. Elevates the legs before applying the stockings: This is a correct action. Elevating the client's legs before applying elastic antiembolic stockings can help reduce swelling and improve blood flow. It's an appropriate step to prepare the client for the stockings.
B. Measures the client's calf circumference before selecting the stocking size: This is a correct action. Proper sizing of elastic antiembolic stockings is crucial to ensure they are effective and do not cause discomfort or complications. Measuring the client's calf circumference helps in selecting the right size.
C. Applies lotion to the client's legs before putting on the stockings: This is an incorrect action. Applying lotion to the legs before putting on stockings can make the stockings less effective and may cause them to slide down. Lotions or creams can create a barrier that interferes with the compression provided by the stockings.
D. Rolls down the stockings from the thigh to the ankle: This is an incorrect action. Elastic antiembolic stockings should be applied carefully, starting at the ankle and rolling them up to the thigh. Rolling them down from the thigh to the ankle is not the correct technique, as it can impede blood flow and be uncomfortable for the client.
So, the correct answers are A and B. These actions indicate that the AP is performing the skill correctly by preparing the client appropriately and ensuring proper sizing of the stockings.
Correct Answer is A
Explanation
Choice A rationale:
Gentamicin is known to have ototoxic effects and can lead to hearing loss, especially when administered via IV infusion. Monitoring for hearing changes is crucial to prevent permanent damage.
Choice B rationale:
Slurred speech is not a common adverse effect of gentamicin. It is more associated with neurological issues or medications affecting the central nervous system.
Choice C rationale:
Hyperthermia is not a typical adverse effect of gentamicin. It may be a sign of infection or another underlying condition but is not directly related to the medication.
Choice D rationale:
Hypotension is not a common adverse effect of gentamicin. It is more commonly associated with medications that affect blood pressure or underlying medical conditions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.