When caring for a child with probable appendicitis, the nurse would be alert to recognize which condition or symptom is a sign of perforation?
Decreased abdominal distention
Anorexia
Bradycardia
Sudden relief from pain
The Correct Answer is D
Choice A reason:
Decreased abdominal distention is not typically a sign of appendicitis perforation. In fact, perforation often leads to increased abdominal distention due to the release of intestinal contents into the abdominal cavity, causing inflammation and swelling. Therefore, this choice is incorrect.
Choice B reason:
Anorexia, or loss of appetite, is a common symptom of appendicitis but not specifically indicative of perforation2. While anorexia can be present in cases of perforation, it is not a definitive sign. The sudden relief of pain is a more critical indicator of perforation, as it suggests the appendix has ruptured, temporarily relieving pressure.
Choice C reason:
Bradycardia, or a slow heart rate, is not a typical sign of appendicitis perforation. In fact, appendicitis and its complications, such as perforation, are more likely to cause tachycardia (an increased heart rate) due to pain and infection. Therefore, this choice is incorrect.
Choice D reason:
Sudden relief from pain is a classic sign of appendicitis perforation. When the appendix ruptures, the pressure inside the appendix is relieved, leading to a temporary decrease in pain. However, this is followed by a rapid onset of severe pain as the contents of the appendix spread throughout the abdominal cavity, causing peritonitis. This sudden change in pain is a critical indicator that the appendix has perforated and requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Bacteriuria, or the presence of bacteria in the urine, is not a primary clinical manifestation of acute renal failure. While facial edema can occur due to fluid retention, bacteriuria is more commonly associated with urinary tract infections. Acute renal failure primarily affects the kidneys’ ability to filter waste and regulate fluid and electrolytes, leading to symptoms such as oliguria and hypertension.
Choice B reason:
Hematuria, or blood in the urine, can be a symptom of various kidney conditions, but it is not a primary manifestation of acute renal failure1. Pallor, or paleness, can occur due to anemia, which may be a secondary complication of chronic kidney disease rather than acute renal failure. The primary symptoms of acute renal failure are related to the sudden decline in kidney function, such as oliguria and hypertension.
Choice C reason:
Proteinuria, or the presence of excess protein in the urine, is more commonly associated with chronic kidney disease or nephrotic syndrome rather than acute renal failure. Muscle cramps can occur due to electrolyte imbalances, but they are not primary manifestations of acute renal failure. The primary symptoms of acute renal failure include oliguria and hypertension.
Choice D reason:
Oliguria, or reduced urine output, and hypertension, or high blood pressure, are primary clinical manifestations of acute renal failure. Acute renal failure results in a sudden decline in kidney function, leading to the retention of waste products and fluids, which can cause oliguria and hypertension. These symptoms are key indicators of acute renal failure and require prompt medical attention.
Correct Answer is C
Explanation
Choice A reason:
I will have my child rest: Resting is an important part of managing a bleeding episode in children with hemophilia. It helps to minimize movement and reduce the risk of further injury or bleeding.
Choice B Reason:
I will compress the site: Applying pressure to the bleeding site is a standard first aid measure for controlling bleeding. Compression helps to slow down or stop the bleeding by promoting clot formation.
Choice C Reason:
I will apply heat: Applying heat is not recommended for managing bleeding in hemophilia. Heat can increase blood flow to the area, potentially worsening the bleeding. Instead, cold compresses or ice packs should be used to constrict blood vessels and reduce bleeding.
Choice D Reason:
I will elevate the affected part: Elevating the affected limb can help reduce blood flow to the area and minimize bleeding. This is a common and effective first aid measure for managing bleeding episodes.
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