Which statement would warrant immediate concern from a nurse caring for a patient with diagnosed appendicitis awaiting surgery?
The patient states, “I think I’m getting better, my pain is all gone now!”
The patient states, “The pain is worse when I move, I can’t get up and go for a walk.”
The patient is stating he is having 7/10 pain in his right lower quadrant
The patient is nauseous and has vomited twice in the past three hours
The Correct Answer is A
Choice A reason: Sudden resolution of pain in appendicitis may indicate perforation, as inflammation spreads beyond the appendix, reducing localized pressure. This is a medical emergency requiring immediate surgical intervention to prevent peritonitis or sepsis, making this statement the most concerning and warranting urgent nurse attention.
Choice B reason: Worsening pain with movement is expected in appendicitis due to peritoneal irritation and inflammation of the appendix. While concerning, it is consistent with uncomplicated appendicitis and less alarming than sudden pain resolution, which suggests perforation, making this statement less urgent for immediate intervention.
Choice C reason: Right lower quadrant pain rated 7/10 is a common symptom of appendicitis, reflecting ongoing inflammation. It is expected and does not indicate an immediate change in condition like perforation. While requiring monitoring, it is less concerning than sudden pain resolution, which signals a critical complication.
Choice D reason: Nausea and vomiting are common in appendicitis due to visceral irritation and inflammation. Vomiting twice in three hours is concerning but expected and does not indicate an immediate emergency like perforation. It requires supportive care but is less urgent than sudden pain resolution in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["83"]
Explanation
Step 1: Convert the child’s weight from pounds to kilograms. 96.8 lbs ÷ 2.2 = 44 kg Result at step 1 = 44 kg
Step 2: Apply the Holliday-Segar formula.
For the first 10 kg: 100 mL/kg × 10 kg = 1000 mL
For the next 10 kg: 50 mL/kg × 10 kg = 500 mL
For the remaining weight (44 kg - 20 kg = 24 kg): 20 mL/kg × 24 kg = 480 mL Result at step 2 = 1000 mL + 500 mL + 480 mL = 1980 mL
Step 3: Adjust for vomiting. Since the child has been vomiting, maintenance fluids are typically not increased unless specified (e.g., for dehydration). The question asks for maintenance fluids, so we use the standard calculation from Step 2. Result at step 3 = 1980 mL for 24 hours
Step 4: Calculate the hourly rate. 1980 mL ÷ 24 hours = 82.5 mL/hour Result at step 4 = 82.5 mL/hour
Step 5: Round to the nearest whole number. 82.5 rounded to the nearest whole number = 83 mL/hour
Final answer 83 mL/hour
Correct Answer is D
Explanation
Choice A reason: Rebound tenderness and low-grade fever suggest peritoneal irritation, often associated with appendicitis or other abdominal conditions. These findings are not specific to tracheoesophageal fistula, which primarily affects the esophagus and trachea, causing respiratory and feeding issues rather than peritoneal inflammation in newborns.
Choice B reason: Bulging fontanel and non-bilious emesis may indicate increased intracranial pressure or gastrointestinal issues like pyloric stenosis. These are not characteristic of tracheoesophageal fistula, which involves a connection between the trachea and esophagus, leading to feeding difficulties and respiratory symptoms rather than fontanel or emesis changes.
Choice C reason: A palpable olive-shaped mass is a hallmark of hypertrophic pyloric stenosis, causing projectile vomiting in infants. This finding is unrelated to tracheoesophageal fistula, which presents with esophageal obstruction or aspiration symptoms due to abnormal connections between the trachea and esophagus, not a palpable abdominal mass.
Choice D reason: Excessive drooling and choking during feeding are classic signs of tracheoesophageal fistula, where an abnormal connection between the trachea and esophagus causes aspiration or inability to swallow effectively. This leads to saliva accumulation and respiratory distress during feeding, making it the most indicative finding in newborns.
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