GI questions
An adolescent who has had an appendectomy and developed peritonitis has nausea. Which of the following should the nurse do first? 1.Administer an antiemetic. 2.Irrigate the nasogastric (NG) tube. 3.Notify the surgeon. 4.Take the blood pressure. (80)
2 R:After an appendectomy, the client who develops peritonitis typically has an NG tube in place. When a client has nausea, the nurse would first check to ensure that the NG tube is functioning correctly, because the client's nausea may be related to a blockage of the NG tube. If the tube is clogged, it can be irrigated with normal saline. An antiemetic may be given, but only after the nurse has determined that the NG tube is functioning properly. Postoperative prescriptions usually include an antiemetic. Typically, the nurse would notify the surgeon if the client did not obtain relief from irrigation of the NG tube or administration of a prescribed antiemetic. Although taking the client's blood pressure is an important postoperative nursing activity, it is unrelated to relieving the client's nausea.
Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent with severe abdominal pain? 1.Abdomen appears slightly rounded. 2.Bowel sounds are heard twice in 2 minutes. 3.All four abdominal quadrants reveal tympany. 4.The client demonstrates a cremasteric reflex. (77)
A: 2 R: Manifestations of appendicitis include decreased or absent bowel sounds. Normally, bowel sounds are heard every 10 to 30 seconds. Therefore, bowel sounds heard twice in 2 minutes suggests appendicitis. Normally, the contour of the male adolescent abdomen is flat to slightly rounded, and tympany is typically heard when auscultating over most of the abdomen. A cremasteric reflex is normal for male adolescents.
An adolescent is being seen in the clinic for abdominal pain with a fever. In what order should the nurse assess the abdomen? 1.Auscultate. 2.Inspect. 3.Palpate. 4.Percuss. (70)
A: 2,1,4,3 R: The nurse should first inspect the abdomen for abnormalities. Auscultation should be done before percussion and palpation as vigorous touching may disturb the intestines. Percussion is next. Palpation is the last step as it is most likely to cause pain.
Which of the following is a normal response from an adolescent who has just returned to her room after an appendectomy? 1."I'll need plastic surgery for this scar." 2."I'm worried about the size of my scar." 3."I don't want to have any pain." 4."What will my boyfriend say about the scar?" (82)
2 R: Adolescents are concerned about the immediate state and functioning of their bodies. The adolescent needs to know whether any changes (eg, illness, trauma, surgery) will alter her lifestyle or interfere with her quest for physical perfection. Having a scar may be devastating to the adolescent. The need for plastic surgery cannot be determined at this point. The adolescent has just returned from surgery and has yet to see the scar. Healing has yet to occur. Typically scars become smaller and fade over time. The desire for no pain is unrealistic. Although adolescents are worried about pain and how they will respond, they typically are discharged within 24 hours after an appendectomy with pain well controlled by oral analgesics. The immediate concern of adolescents is the state and functioning of their bodies. After concerns about themselves, then adolescents are concerned about their peer group and their responses. Although the boyfriend's response will matter, this concern would be more common later in the course of the adolescent's recovery.
When developing the postoperative plan of care for an adolescent who has undergone an appendectomy for a ruptured appendix, in which of the following positions should the nurse expect to place the client during the early postoperative period? 1.The semi-Fowler's position. 2.Supine. 3.Lithotomy position. 4.Prone. (81)
A: 1 R: After an appendectomy for a ruptured appendix, assuming the semi-Fowler's or a right side-lying position helps localize the infection. These positions promote drainage from the peritoneal cavity and decrease the incidence of subdiaphragmatic abscess.
An adolescent male client scheduled for an emergency appendectomy is to be transferred directly from the emergency room to the operating room. Which of the following statements by the client should the nurse interpret as most significant? 1."All of a sudden it doesn't hurt at all." 2."The pain is centered around my navel." 3."I feel like I'm going to throw up." 4."It hurts when you press on my stomach." (78)
A: 1 R: Sudden relief of pain in a client with appendicitis may indicate that the appendix has ruptured. Rupture relieves the pressure within the appendix but spreads the infection to the peritoneal cavity. Periumbilical pain (pain centered around the navel), vomiting, and abdominal tenderness on palpation are common findings associated with appendicitis.
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which of the following nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply. 1.Offer an ice pack. 2.Apply a heating pad. 3.Encourage the child to assume a position of comfort. 4.Limit the child's activity. 5.Request a prescription for a cathartic. 6. Administer pain medication (71)
A: 1,3,4 R:Cold is a vasoconstrictor and supplies some degree of anesthesia. The child is usually more comfortable on his side with his legs flexed to take the strain off the inflamed appendix. Limiting the child's activity puts less stress on the inflamed appendix and lessens the discomfort. Heat increases circulation to an area, causing more engorgement and pain and, possibly, rupture of the appendix. Heat is contraindicated in any situation where rupture or perforation is a possibility. A cathartic is contraindicated when appendicitis is suspected. Increasing peristalsis can cause the appendix to rupture. Pain medication masks symptoms of perforation.
A 10-year old male is 24 hours postappendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN pain. What is the priority nursing action in managing the child's pain? 1.Change the child's position in bed. 2.Obtain vital signs with a pain score. 3.Administer 1 mg morphine as prescribed. 4.Perform a head to toe assessment. (72)
A: 2 R: The child is in pain and needs intervention but before the nurse can determine how to proceed, it is essential to know the client's pain score to determine the appropriate morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child's position and administering pain medication may be helpful to relieve the child's pain but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head to toe assessment however it is not the priority in managing the child's pain.
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." The nurse should: 1.Explain that completing a teaching checklist is required by the hospital. 2.Help the client find information on the Internet. 3.Provide the client with written information instead. 4.Explain that information found on the Internet cannot be trusted. (84)
A: 2 R:Part of providing client-centered care is to honor the client's preferred method of learning. The nurse should help the adolescent find accurate information about the procedure. By assisting with the information search the nurse can verify learning. Teaching straight from a checklist does not encourage customization. If the client has requested to use the Internet, it is unlikely that written information will be read. While it is true that some information on the Internet is not accurate, the nurse can take this opportunity to help the client learn how to determine if a source is reliable.
When developing the plan of care for a school-age child with a suspected diagnosis of appendicitis who has severe abdominal pain, which of the following measures should the nurse expect to include in the child's plan of care? 1.Application of a heating pad. 2.Insertion of a rectal tube. 3.Application of an ice bag. 4.Administration of an intravenous narcotic. (76)
A: 3 R: Application of an ice bag may help to relieve pain by decreasing circulation to the area. A heating pad is contraindicated because heat may increase circulation to the appendix, possibly leading to rupture. Rectal tubes are contraindicated because they stimulate bowel motility and can exacerbate abdominal pain. Also, they would be ineffective "because accumulation of gas in the lower bowel is not likely to be the cause of the child's discomfort. Because narcotics can mask the child's symptoms, such as pain and discomfort, and they also decrease bowel motility, they are not given until after a definitive diagnosis has been made.
A 5-year-old child is experiencing pain after an appendectomy. Which data collection tool should the nurse use to assess the pain? 1.Visual analog scale. 2.FLACC scale. 3.Numerical pain scale. 4.FACES pain rating scale. (73)
A: 4 R: The nurse should use the FACES pain rating scale for children aged three or older. The visual analog and numerical scales are used with adults. The FLACC (faces-legs-activity-cry-consolability) scale is a behavioral scale that is appropriate for very small children or nonverbal children.
Which of the following should be the priority assessment for an adolescent on return to the nursing unit after an appendectomy? 1.The dressing on the surgical site. 2.Intravenous fluid infusion site. 3.Nasogastric (NG) tube function. 4.Amount of pain. (79)
A:1 R: The priority assessment after an appendectomy would be the dressing over the surgical site to determine whether there is any drainage or bleeding. The surgical dressing should be clean, dry, and intact. Once the dressing has been assessed, the nurse would assess the intravenous infusion site, assess the NG tube to be sure it is functioning, and finally, determine the degree of pain the client is experiencing.
Which of the following client actions should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy? 1.Insisting on wearing a T-shirt and gym shorts rather than pajamas. 2.Avoiding interactions with other adolescents on the nursing unit. 3.Refusing to fill out the menu, and allowing the nurse to do so. 4.Not taking telephone calls from friends so he can rest. (83)
A:1 R:Adolescents struggle for independence and identity, needing to feel in control of situations and to conform to peers. Control and conformity are often manifested in appearance, including clothing, and this carries over into the hospital experience. The adolescent feels best when he is able to look and act as he normally does, for example, wearing a T-shirt and gym shorts. Adolescents normally want to interact with peers and commonly seek every opportunity to do so. Avoiding other adolescents on the nursing unit or not taking phone calls from friends might suggest ineffective coping behavior. Refusing to fill out the menu and allowing the nurse to do so demonstrate dependent behavior, not a healthy coping mechanism.
When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis? 1."Where did the pain start?" 2."What did you do for the pain?" 3."How often do you have a bowel movement?" 4."Is the pain continuous, or does it let up?" (75)
A:1 R: The most helpful question would be to determine the location of the pain when it started. The pain associated with appendicitis usually begins in the periumbilical area, and then progresses to the right lower quadrant. After the nurse has determined the location of the pain, asking about what was done for the pain would be appropriate. Asking about the child's usual bowel movement pattern is a general question unrelated to child's condition. Children with appendicitis may have diarrhea or constipation. Additionally, knowledge about the child's usual pattern would not be a priority because the child with appendicitis typically is not hospitalized long enough to reestablish the normal pattern. Although the characteristics of the pain are important, asking if the pain is continuous or intermittent is vague and general because the pain could be associated with numerous conditions. With appendicitis, the client's pain may begin as intermittent, but it eventually becomes continuous.
