Answer to Question 1
ANS: D
A positive heel-drop jarring test involves having the patient stand on his or her toes for 15 seconds then drop onto the heels. Pain elicited with this assessment is indicative of appendicitis. The patient may also wince when getting off the examination table. The nurse should notify the provider immediately. Pain is nonspecific and needs treatment, but does not need immediate action. A negative obturator sign is normal, as is the lack of rebound tenderness.
Answer to Question 2
ANS: C
No specific diagnostic tests exist for failure to thrive (FTT); however, there are several assessment criteria that can be used to identify children at risk for FTT. One such criterion is weight for age and sex below the 5th percentile. Asking questions about feeding is appropriate. Demonstrating improper burping technique creates an opportunity for teaching the correct process. Improper burping combined with other risk factors may be a concern. Weight for length less than the 85th percentile of ideal weight is a concern, so this child has a normal weight-for-length finding.
A nurse adjusts the rate of a client’s IV.
A child having a seizure is gently assisted to the floor and placed in a sidelying position.
Mechanisms of pain at the nociceptor level
Fall assessment tool
Eqiupment and supplies for physical assessment
Patient teaching: lung assessment