The nurse is caring for a client who presents with acute appendicitis:
Select all that apply?
Creatinine, 0.9 mg/dL
White blood cell count, 11,500 mm"
BUN 26 mg/dL.
Reports of pain increasing while coughing
Potassium 3.3 mEq/L
Nausea and vomiting
Correct Answer : B,C,D,E
Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.
Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.
Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.
Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.
Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.
Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Activates the rapid response team (RRT) - Status epilepticus is a medical emergency requiring immediate intervention. Activating the rapid response team would ensure a prompt response to the situation.
Choice B rationale: Loosens any restrictive clothing - It is important for patient safety and comfort.
Choice C rationale: Places the client in a lateral position - This is a recommended positioning to prevent aspiration during a seizure.
Choice D rationale: Prepares to administer intravenous valproate acid - Valproic acid is not the first drug during epilepsy hence this action would necessitate immediate intervention.
Correct Answer is C
Explanation
Choice A rationale: Conus medullaris syndrome involves injury or compression to the end portion of the spinal cord and can present with various symptoms but not necessarily lack of normal sympathetic outflow leading to shock.
Choice B rationale: Concussion is a mild traumatic brain injury, and the symptoms described align more with spinal cord injury leading to neurogenic shock.
Choice C rationale: Neurogenic shock occurs due to the loss of sympathetic tone and is characterized by bradycardia, low blood pressure, and vasodilation following spinal cord injury at or above the level of the sixth thoracic vertebra.
Choice D rationale: Diffuse axonal injury typically presents with more widespread brain injury-related symptoms and is not associated with the specific spinal cord-related symptoms described.
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