A nurse is collecting data from a client who has been admitted with suspected appendicitis. Which of the following findings is the nurse's priority to report to the provider?
Temperature 37.8° C (100° F)
Loss of appetite
WBC count 15,000/mm³
Rigid, board-like abdomen
The Correct Answer is D
Choice A reason: This is not a priority finding to report to the provider because temperature 37.8° C (100° F) indicates a mild fever that can be caused by inflammation or infection of the appendix or other organs. The nurse should monitor the client's temperature and administer antipyretics as prescribed.
Choice B reason: This is not a priority finding to report to the provider because loss of appetite is a common symptom of appendicitis that can result from nausea, vomiting, or pain. The nurse should encourage oral fluid intake and provide clear liquids or bland foods as tolerated.
Choice C reason: This is not a priority finding to report to the provider because WBC count 15,000/mm³ indicates leukocytosis or elevated white blood cell count that can be caused by inflammation or infection of the appendix or other organs. The nurse should monitor the client's laboratory values and administer antibiotics as prescribed.
Choice D reason: This is a priority finding to report to the provider because rigid, board-like abdomen indicates peritonitis or inflammation of the peritoneum that can be caused by rupture or perforation of the appendix or other organs. This is a medical emergency that requires immediate surgical intervention and aggressive fluid and antibiotic therapy. The nurse should assess the client's abdominal pain, distension, and guarding and notify the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is an accurate information because moderate sedation, also known as conscious sedation, is a type of anesthesia that reduces anxiety and pain during the colonoscopy without causing loss of consciousness. The nurse should inform the client that they will need someone to drive them home after the procedure and that they may experience some drowsiness, nausea, or sore throat.
Choice B reason: This is not an accurate information because the client should drink only clear liquids, such as water, tea, broth, or juice, until 4 hours before the procedure. Full liquids, such as milk, cream, or soup, can interfere with the bowel preparation and obscure the visibility of the colon.
Choice C reason: This is not an accurate information because the client should drink the liquid bowel preparation as prescribed by the provider, usually cold or at room temperature. Warming the liquid bowel preparation may alter its effectiveness and taste.
Choice D reason: This is not an accurate information because the client will lie on their left side for the procedure, not on their right side. Lying on the left side allows better access and visualization of the colon by the endoscope.
Correct Answer is C
Explanation
Choice A reason: This is not an appropriate action because keeping the lights dimmed can increase the risk of falls, confusion, or agitation in the client who has Alzheimer's disease. The nurse should provide adequate lighting and reduce glare and shadows in the client's room and environment.
Choice B reason: This is not an appropriate action because alternating the client's daily routine can cause stress, anxiety, or frustration in the client who has Alzheimer's disease. The nurse should maintain a consistent and structured routine and schedule for the client and provide cues and reminders as needed.
Choice C reason: This is an appropriate action because participating in reminiscence therapy with the client can enhance their cognitive function, mood, and self-esteem by stimulating their long-term memory and encouraging them to share their past experiences, feelings, and values. The nurse should use photos, music, or objects that are meaningful to the client and listen actively and respectfully.
Choice D reason: This is not an appropriate action because raising the four side rails on the client's bed can be considered a form of restraint that can harm or injure the client who has Alzheimer's disease. The nurse should use alternative measures to ensure the client's safety and comfort, such as lowering the bed, using a bed alarm, or providing frequent supervision.
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