when caring for a child with probable appendicitis the nurse should be alert to recognize which sign or symptom as a manifestation of perforation
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation?

Correct answer: C

Rationale: When caring for a child with probable appendicitis, sudden relief from pain is a critical sign that could indicate perforation of the appendix. Perforation results in the release of pressure and inflammation, leading to a temporary relief of pain. Anorexia (loss of appetite) and decreased abdominal distention are symptoms commonly associated with appendicitis itself, not perforation. Bradycardia (slow heart rate) is not typically a direct manifestation of appendicitis or its complications.

2. The nurse is teaching a client to prevent future urinary tract infections (UTIs). What factor is most important to emphasize as the potential cause?

Correct answer: C

Rationale: Urinary stasis is the most important factor in the development of UTIs because it provides an environment for bacterial growth. While poor hygiene and congenital anomalies are contributing factors, preventing urinary stasis is key in UTI prevention.

3. The nurse is teaching parents about the effects of media on childhood obesity. The nurse realizes the parents understand the teaching if they make which statements? (Select all that apply.)

Correct answer: D

Rationale: Increased screen time is associated with unhealthy habits, such as poor sleep and snacking, which contribute to obesity, but it does not necessarily improve nutrition knowledge.

4. The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children’s pain assessment?

Correct answer: A

Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.

5. At what stage can infants raise their heads and gain control of their trunks before walking due to which directional pattern of development?

Correct answer: A

Rationale: The correct answer is A: Cephalocaudal. The cephalocaudal pattern of development means that growth and motor control proceed from the head downward through the body. This explains why infants can raise their heads before they can sit and gain control of their trunks before walking. Choices B, C, and D are incorrect. Anterior to posterior refers to development from the front to the back, while proximodistal refers to development from the center of the body outward. Normal growth curve charts are used to track physical growth over time and are not directly related to the directional pattern of development in infants.

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