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. Which are included in the evaluation step of the nursing process? (Select all that apply.)

Correct answer: A

Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.

3. The nurse manager is compiling a report for a hospital committee on the quality of nursing-sensitive indicators for a nursing unit. Which does the nurse manager include in the report?

Correct answer: C

Rationale: The education and certification of nurses are key nursing-sensitive indicators that reflect the quality of care provided on the unit.

4. The parent of a 3-month-old infant is concerned because the infant is not able to sit independently. How should the nurse respond to this parent's concern?

Correct answer: D

Rationale: The correct answer is D because sitting steadily typically occurs closer to 6-8 months of age, not 3 or 4 months. Choice A is incorrect because sitting ability and the age of first tooth eruption are not related. Choice B and C are incorrect as most infants do not sit steadily at 3 or 4 months, and it is more common for infants to achieve this milestone around 6-8 months.

5. At a well-child check-up, the nurse notes that an infant with a previous diagnosis of failure to thrive (FTT) is now steadily gaining weight. The nurse should recommend that fruit juice intake be limited to no more than how much?

Correct answer: A

Rationale: The American Academy of Pediatrics recommends limiting fruit juice intake to no more than 4 oz per day for infants, as excessive juice can contribute to poor nutrition and dental issues.

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