The nurse reviews the chart and signs the order: “Paracentesis now, to rule out spontaneous bacterial peritonitis.” What will the nurse include in the plan of care? (Select all that apply)

Obtain vital signs every hour postprocedure

Have the patient void

Check for a signed consent form

Post-procedure, encourage early ambulation

Send fluid for lab analysis

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason: Obtaining vital signs every hour post-paracentesis monitors for complications like bleeding or hypovolemia, as the procedure removes peritoneal fluid, potentially causing hemodynamic instability. Frequent monitoring ensures early detection of hypotension, tachycardia, or other signs of complications, ensuring patient safety after this invasive procedure targeting spontaneous bacterial peritonitis.

Choice B reason: Having the patient void before paracentesis prevents bladder puncture, as a full bladder elevates the risk during needle insertion into the peritoneal cavity. Emptying the bladder ensures a safer procedure by reducing the risk of organ injury, a critical step in preparing for paracentesis to diagnose spontaneous bacterial peritonitis.

Choice C reason: Checking for a signed consent form is essential, as paracentesis is an invasive procedure requiring informed consent. This ensures the patient understands risks, benefits, and alternatives, adhering to ethical and legal standards. Confirming consent is a critical pre-procedure step to diagnose spontaneous bacterial peritonitis safely and appropriately.

Choice D reason: Encouraging early ambulation post-paracentesis is not standard, as patients may require monitoring for complications like bleeding or hypotension. Rest is typically advised initially to ensure stability. Ambulation may increase intra-abdominal pressure or risk complications, making it inappropriate in the immediate post-procedure care plan for this condition.

Choice E reason: Sending fluid for lab analysis is critical in paracentesis to diagnose spontaneous bacterial peritonitis. The fluid is tested for cell count, bacteria, and protein to confirm infection. This analysis guides antibiotic therapy and management, making it an essential component of the care plan to address the suspected bacterial infection.

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Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Decreased appetite is not typical in Graves’ disease, a form of hyperthyroidism. Increased metabolism from elevated thyroid hormones increases appetite, yet weight loss occurs due to catabolism. Decreased appetite may occur in hypothyroidism or other conditions, not hyperthyroidism, making this an incorrect expected finding.

Choice B reason: Muscle enlargement is not associated with Graves’ disease. Hyperthyroidism causes muscle wasting and weakness due to increased catabolism from elevated thyroid hormones. Muscle enlargement occurs in conditions like myopathies or anabolic states, not hyperthyroidism, where protein breakdown predominates, leading to reduced muscle mass.

Choice C reason: Weight loss is a hallmark of Graves’ disease, as excess thyroid hormones increase metabolic rate, accelerating calorie expenditure. Despite increased appetite, patients lose weight due to enhanced catabolism of fat and muscle. This is a classic symptom, reflecting the hypermetabolic state driven by hyperthyroidism.

Choice D reason: Fine tremor is a common finding in Graves’ disease, caused by excess thyroid hormones increasing sympathetic nervous system activity. This leads to beta-adrenergic stimulation, causing fine, resting tremors, particularly in the hands. It’s a key neurological symptom, reflecting the hyperthyroid state’s impact on motor control.

Choice E reason: Goiter, an enlarged thyroid gland, is a classic feature of Graves’ disease. Autoimmune stimulation by thyroid-stimulating antibodies causes thyroid hyperplasia, leading to a visible or palpable goiter. This enlargement is a hallmark of Graves’ disease, driven by increased thyroid hormone production, and is a key physical finding expected during assessment of this hyperthyroid condition.

A. Neutrophils 3,000/mm³ B. Lymphocytes 3,000/mm³ C. WBC 17,000/mm³ D. RBC 4.2 million/mm³

Correct Answer is C

Explanation

Choice A reason: Neutrophils 3,000/mm³ is below the normal range (4,000–11,000/mm³) and not expected in appendicitis, which causes neutrophilia due to bacterial inflammation. Elevated neutrophils (70–80% of WBCs) reflect the body’s immune response to infection, making a low neutrophil count inconsistent with acute appendicitis’s inflammatory profile.

Choice B reason: Lymphocytes 3,000/mm³ is within normal range but not specifically elevated in appendicitis. Lymphocytosis is more common in viral infections. Appendicitis typically causes neutrophilia and elevated total WBCs due to bacterial inflammation, so lymphocyte count alone is not a key diagnostic indicator for this condition.

Choice C reason: A WBC count of 17,000/mm³ indicates leukocytosis, typical in acute appendicitis due to bacterial infection and inflammation. Neutrophils predominate, reflecting the immune response to appendiceal inflammation. This elevated count is a key lab finding, supporting the diagnosis and indicating the need for surgical intervention like appendectomy.

Choice D reason: RBC 4.2 million/mm³ is within normal range and unaffected in appendicitis unless significant bleeding occurs, which is rare. Appendicitis primarily causes inflammation, elevating WBCs, not altering RBC counts. This value is not a diagnostic indicator, as appendicitis does not typically impact red blood cell production or loss.

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The nurse reviews the chart and signs the order: “Paracentesis now, to rule out spontaneous bacterial peritonitis.” What will the nurse include in the plan of care? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient who has Graves’ disease. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this patient’s laboratory values?

Correct Answer is C

Explanation

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