Exhibits

For each potential assessment finding, click to specify if the finding is consistent with Crohn’s disease, appendicitis or intussusception. Each finding may support more than 1 disease process.

Temperature

Vomiting

Abdominal findings

Stool

Pain rating

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"A,C"},"E":{"answers":"B,C"}}

Rationale:

Temperature: The child’s temperature is 37.4°C (99.3°F), which is mildly elevated. Crohn’s disease typically causes intermittent fever during flare-ups. Appendicitis often presents with a higher fever in later stages. Intussusception can cause low-grade fever due to bowel inflammation, making it the most consistent with this finding.
Vomiting: Vomiting is uncommon in Crohn’s disease unless there’s obstruction or severe disease. In appendicitis, vomiting usually follows the onset of pain and is related to peritoneal irritation. Intussusception often involves vomiting early due to intermittent bowel obstruction, making it consistent with this client’s symptoms.
Abdominal findings: Crohn’s disease rarely produces a palpable abdominal mass or sudden distension. Appendicitis can cause right-sided tenderness and decreased bowel sounds but does not typically involve a mass. Intussusception often presents with a distended abdomen, hypoactive bowel sounds, and a sausage-shaped mass in the right upper quadrant, as described.
Stool: Crohn’s disease can lead to bloody, mucus-filled stools due to ulceration in the intestinal lining. Appendicitis does not typically alter stool characteristics unless perforation occurs. Intussusception is well known for producing “currant jelly” stools, composed of blood and mucus, aligning with this child’s bowel movement description.
Pain rating: A FLACC score of 5 indicates moderate pain. Crohn’s pain tends to be chronic and crampy rather than episodic. Appendicitis pain worsens over time and becomes localized, typically in the right lower quadrant. Intussusception causes intermittent, severe abdominal pain with sudden relief, matching the child’s pain episodes and behavior.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Massage the client's legs once every 8 hr while the stockings are in place: Massaging the legs of a client at risk for thromboembolism is discouraged, as it could dislodge a clot and lead to a pulmonary embolism. Mechanical methods like stockings are preferred for promoting circulation.

B. Fold the top of the stocking over neatly: Folding the stockings creates a tourniquet effect, restricting venous return and potentially increasing the risk of venous stasis or skin breakdown. Stockings should remain flat and unfolded.

C. Determine if the stockings are binding: It’s important to assess for tightness, especially at the toes and calves, to ensure proper circulation and prevent pressure injuries. Stockings should fit snugly but not impair blood flow.

D. Apply the stockings after the client is in a chair: Stockings are most effective when applied while the client is in a supine position, before blood pools in the lower extremities. Delayed application reduces their preventive benefit.

A. Apply the largest cuff available B. Use the palpatory method to determine blood pressure C. Place the arm above the level of the client's heart D. Deflate the cuff quickly

Correct Answer is B

Explanation

Rationale:

A. Apply the largest cuff available: Using a cuff that is too large for the client can yield inaccurately low readings. Cuff size should match the client’s arm circumference, not be chosen randomly or for convenience.

B. Use the palpatory method to determine blood pressure: When auscultation is difficult, the palpatory method helps estimate the systolic pressure by palpating the radial pulse. This guides proper cuff inflation and avoids missing the auscultatory gap.

C. Place the arm above the level of the client's heart: Elevating the arm above heart level can result in falsely low readings. The arm should be supported at heart level to obtain accurate results.

D. Deflate the cuff quickly: Rapid deflation can cause the nurse to miss key Korotkoff sounds, leading to an inaccurate measurement. Cuff deflation should be slow and controlled (2–3 mm Hg/sec).

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Exhibits For each potential assessment finding, click to specify if the finding is consistent with Crohn’s disease, appendicitis or intussusception. Each finding may support more than 1 disease process.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Complete the following sentence by using the lists of options. Based on the client findings, the nurse should first dropdown and then prepare to administer dropdown.

A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

A nurse is caring for a client in active labor. Exhibits The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?

A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

A nurse is preparing to administer levothyroxine 50 mcg to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

Exhibits

For each potential assessment finding, click to specify if the finding is consistent with Crohn’s disease, appendicitis or intussusception. Each finding may support more than 1 disease process.