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

Choice A rationale:

Increasing the client's intake of oral fluids may not address the underlying issue of crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. This client likely has fluid accumulation in the lungs, and simply increasing fluid intake could exacerbate the problem. It's important to assess and manage the client's fluid balance carefully.

Choice B rationale:

Instructing the client to cough every 4 hours may not be sufficient for managing the client's symptoms, especially if there is fluid in the lungs. Coughing alone may not adequately clear the airways. More intensive interventions are needed.

Choice C rationale:

The correct action is to "Maintain the client in high-Fowler's position." High-Fowler's position helps improve lung expansion and oxygenation by allowing the client to sit up at an angle, which reduces pressure on the diaphragm and improves lung mechanics. This position can help alleviate symptoms such as crackles and shortness of breath in clients with heart failure.

Choice D rationale:

Encouraging the client to ambulate to loosen secretions may not be appropriate in this case. Ambulation is generally encouraged for clients with adequate oxygenation and mobility. If the client has severe respiratory distress, it's crucial to address that issue first before considering ambulation.

A. Hegar's sign. B. Chloasma. C. Ballottement. D. Chadwick's sign.

Correct Answer is D

Explanation

Choice A rationale:

Hegar's sign is a softening of the uterine isthmus, which occurs during early pregnancy. It is not related to changes in the color of the vagina and vulva.

Choice B rationale:

Chloasma refers to the appearance of dark, blotchy, and hyperpigmented skin patches that can occur during pregnancy, primarily on the face. It is not related to changes in the color of the vagina and vulva.

Choice C rationale:

Ballottement is a technique used during a physical examination to assess for a floating fetus within the amniotic fluid. It is not related to changes in the color of the vagina and vulva.

Choice D rationale:

Chadwick's sign is the purplish or bluish discoloration of the vaginal and vulvar mucosa that can occur during pregnancy. This sign is due to increased blood flow to the area, which is a normal physiological change in pregnancy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has heart failure.The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.The nurse notes that the client's vagina and vulva are a purplish color.The nurse should document this finding as which of the following?

Correct Answer is D

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?