A nurse is caring for an adolescent who is 1 hr. postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
Muscle rigidity
Abdominal pain
Heart rate 63/min
Temperature 36.4° C (97.5" F)
The Correct Answer is A
Choice A Reason:
Muscle rigidity is correct. Muscle rigidity can indicate several concerning issues postoperatively, such as complications from anesthesia, infection, or other underlying problems. It's crucial to report this finding promptly to the provider for further evaluation and appropriate management.
Choice B Reason:
Some degree of abdominal pain is expected post-appendectomy, but the severity and persistence of the pain should be assessed further.
Choice C Reason:
Heart rate of 63/min is within the normal range for some adolescents and might not be an immediate concern unless there are other accompanying symptoms.
Choice D Reason:
A temperature of 36.4°C (97.5°F) falls within the normal range for body temperature and might not be a cause for immediate concern unless it's accompanied by other symptoms or if there are signs of temperature changes (like fever) over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"Are you willing to take new parenting classes?" This question is about the parent's willingness to seek additional education rather than exploring their current coping methods.
Choice B Reason:
"What do you do when your infant is fussy?" is correct. This question invites the parent to share their strategies for managing their infant's fussiness, allowing the nurse to gain insight into the parent's coping mechanisms and caregiving approaches. It acknowledges the challenges of dealing with a fussy infant while providing an opportunity for the parent to discuss their techniques for soothing or calming the baby.
Choice C Reason:
"Is it overwhelming when your infant is having a bad day?" While this question acknowledges the potential stress the parent may experience, it might not directly invite discussion about coping mechanisms or strategies.
Choice D Reason:
"Does parenting because you stress?" This question directly addresses stress but might not encourage the parent to discuss specific coping mechanisms or strategies they use when faced with challenging situations.
Correct Answer is A
Explanation
Choice A Reason:
Bradycardia is correct. This is because bradycardia, or a slower than normal heart rate, can indeed be an indicator of digoxin toxicity. Digoxin is a medication that affects the heart's rhythm, and toxicity can lead to an excessively slow heart rate among other symptoms.
Choice B Reason:
Jaundice is incorrect. Jaundice, characterized by yellowing of the skin and eyes due to elevated bilirubin levels, is not commonly associated with digoxin toxicity. It's more indicative of liver-related issues rather than digoxin toxicity.
Choice C Reason:
Diaphoresis is incorrect. Diaphoresis, or excessive sweating, is not typically a primary symptom of digoxin toxicity. While various medications or medical conditions can cause diaphoresis, it's not a common indicator of digoxin toxicity.
Choice D Reason:
Polyuria is incorrect. Polyuria, excessive urination, is not a typical symptom of digoxin toxicity. It's not a direct effect of the medication on the body's systems.
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