A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?
"My belly doesn't hurt anymore."
"I am hungry and thirsty."
"I'm tired and want to take a nap."
"I am scared and I want to go home."
The Correct Answer is A
A. "My belly doesn't hurt anymore."
- This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.
B. "I am hungry and thirsty."
- While it's normal for a child to feel hungry and thirsty, especially if they have been experiencing nausea and vomiting, this statement is not necessarily concerning on its own. However, in the context of suspected appendicitis and severe right lower quadrant pain, it's important for the child to remain NPO (nothing by mouth) to prevent complications in case surgery is needed.
C. "I'm tired and want to take a nap."
- Feeling tired and wanting to rest is not uncommon, especially if the child has been experiencing discomfort or pain for a prolonged period. While this statement may indicate fatigue, it's not inherently concerning in the context of suspected appendicitis. However, it's important for the nurse to monitor the child's energy level and overall condition.
D. "I am scared and I want to go home."
- It's understandable for a child to feel scared or anxious, particularly when facing a medical procedure such as surgery. While this statement reflects the child's emotions, it doesn't necessarily indicate a change in their medical condition. However, it's important for the nurse to address the child's fears and provide emotional support while ensuring that the child receives appropriate medical care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Maintain a saline-lock:
While maintaining a saline lock is important for ensuring vascular access in case of emergency, it is not the priority action in caring for a child with acute glomerulonephritis. Monitoring fluid balance and electrolyte levels may be necessary, but the immediate priority is to educate the parents about potential complications.
B. Check the child's weight daily:
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet:
Dietary modifications, including reducing salt intake, may be recommended for managing acute glomerulonephritis. However, it is not the priority action at this stage.
D. Educate the parents about potential complications:
Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
Correct Answer is A
Explanation
A. Firmly attached white particles on the hair:
Firmly attached white particles on the hair are characteristic of nits, which are the eggs of lice. While this finding supports the diagnosis of pediculosis capitis, it is not a definitive indication on its own.
B. Itching and scratching of the head:
Itching and scratching of the head are common symptoms of pediculosis capitis. However, they are also common symptoms of various other scalp conditions, so they are not definitive indications.
C. Thick, yellow-crusted lesions on a red base:
This description is more characteristic of impetigo, a bacterial skin infection, rather than pediculosis capitis. Impetigo typically presents with yellow-crusted lesions on a red base, but it does not involve lice infestation.
D. Patchy areas of hair loss:
Patchy areas of hair loss are not typically associated with pediculosis capitis. This finding is more suggestive of conditions like alopecia areata or fungal infections.
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