A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis?

A. A high specific gravity of urine typically indicates concentrated urine, which can occur in dehydration; however, moist mucous membranes suggest adequate hydration. This combination does not indicate severe dehydration.
B. A low specific gravity of urine usually indicates dilute urine, which is not typical in dehydration; it suggests the kidneys are not concentrating urine due to good fluid intake or other factors. While pale skin can indicate poor perfusion, this option does not specifically indicate severe dehydration.
C. A depressed fontanelle (soft spot on the head) and a capillary refill time greater than 4 seconds are significant indicators of severe dehydration in infants. Depressed fontanelles suggest that the infant is not receiving enough fluids, and prolonged capillary refill time indicates poor perfusion and dehydration.
D. Moist skin and mucous membranes indicate adequate hydration. Flushed skin may occur with certain conditions but does not suggest severe dehydration. This option reflects a well-hydrated status rather than dehydration.

A. Oral feeding supplements are often included in the care plan for clients with malnutrition. They provide additional calories and nutrients that can help improve the client's nutritional status and support recovery. This is an appropriate prescription.
B. Daily weights are essential in monitoring the client’s fluid status and overall nutritional progress.
Weight changes can indicate improvements or worsening of the client’s condition, particularly in cases
of malnutrition or fluid retention. This is a valuable prescription.
C. A low protein diet is generally not appropriate for a client with anemia and malnutrition. Protein is essential for healing, maintaining muscle mass, and overall health. Instead, the care plan should emphasize adequate protein intake to support recovery and address nutritional deficiencies.
D. Monitoring pre-albumin levels is crucial in assessing the client's nutritional status. Pre-albumin is a sensitive marker for protein status and can help gauge the effectiveness of nutritional interventions. This is an important prescription to include.
E. Keeping a calorie count helps assess the client's intake and ensure that they are receiving adequate nutrition. This information is vital for adjusting the dietary plan as needed to meet the client’s caloric and nutritional needs. Therefore, this is a relevant prescription.