A nurse is planning care for a client who has acute appendicitis.
Which of the following actions should the nurse plan to take?
Administer a laxative to the client.
Keep the client on NPO status.
Place the client's head of bed flat.
Apply heat to the client's abdomen.
The Correct Answer is B
Choice A rationale:
Administering a laxative to a client with acute appendicitis is contraindicated. Laxatives can increase bowel motility, which may aggravate the inflamed appendix and lead to rupture. Rupture of the appendix can result in a life-threatening condition known as peritonitis.
Choice B rationale:
Keeping the client on NPO (nothing by mouth) status is the correct choice. NPO status is essential in the management of acute appendicitis. It helps to rest the bowel, prevents stimulation of the appendix, and decreases the risk of rupture. Oral intake, including food and fluids, is usually restricted until the client undergoes surgery to remove the inflamed appendix (appendectomy).
Choice C rationale:
Placing the client's head of bed flat is not the optimal position for a client with acute appendicitis. Elevating the head of the bed slightly (semi-Fowler's position) can help reduce discomfort and minimize pressure on the abdomen. This position is more comfortable for the client and can aid in pain management.
Choice D rationale:
Applying heat to the client's abdomen is not recommended in acute appendicitis. Heat application can increase blood flow to the area, potentially worsening inflammation and exacerbating pain. Cold packs or ice packs are sometimes used to provide comfort, but their application should be done cautiously to avoid skin damage. However, in many cases, healthcare providers prefer to avoid temperature applications to prevent masking symptoms and signs of worsening appendicitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Borderline personality disorder is characterized by impulsivity, unstable relationships, and mood swings. While individuals with this disorder may have concerns about details, it is not the primary characteristic of the disorder. The impulsivity exhibited by these clients is a more prominent feature.
Choice B rationale:
While individuals with borderline personality disorder may struggle with interpersonal relationships and may sometimes display seductive behavior, this is not a defining characteristic of the disorder. The primary concern lies in their impulsivity and emotional instability.
Choice C rationale:
Clinginess can be a feature of borderline personality disorder, but it is not the defining characteristic. The disorder is more accurately characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects, marked impulsivity that begins by early adulthood and is present in various contexts.
Choice D rationale:
Borderline personality disorder is indeed marked by impulsive behavior, one of the key diagnostic criteria according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). This impulsivity often leads to self-damaging behaviors, such as reckless driving, substance abuse, and unsafe sex. Including this information in the in-service is crucial for an accurate understanding of the disorder.
Correct Answer is B
Explanation
Choice A rationale:
Belching is a common finding following an esophagogastroduodenoscopy and is not a cause for concern unless it is excessive or accompanied by other concerning symptoms.
Choice B rationale:
(Correct Choice) Abdominal pain after an esophagogastroduodenoscopy can indicate complications such as perforation, bleeding, or infection. It is essential to report this finding to the provider promptly for further evaluation and management.
Choice C rationale:
Sore throat is a common and expected side effect after the procedure due to irritation from the endoscope. It usually resolves on its own and does not require immediate reporting unless it worsens or is associated with other concerning symptoms.
Choice D rationale:
Flatulence is not typically related to an esophagogastroduodenoscopy and is not a cause for concern in this context.
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