A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client's signs/symptoms is:

Correct Answer: A

Rationale: The client's signs and symptoms point towards a diagnosis of peritonitis, which is an inflammation of the peritoneum lining the abdominal cavity. The presence of severe, constant abdominal pain, rigid abdominal muscles, rebound tenderness, hypotension, and tachycardia are all indicative of peritonitis. These symptoms are typically seen when there is an infection or inflammation in the abdominal cavity, leading to fluid shifting from the intravascular space to the peritoneal cavity. This shifting of fluid results in hypovolemia, causing hypotension and tachycardia.

Correct Answer: D

Rationale: At this age, building a tower involves fine motor skills and symbolic thinking.

Correct Answer: A

Rationale: Nosocomial pneumonia occurs in a healthcare setting. It is a type of pneumonia that is contracted during a hospital stay or other healthcare facilities. The risk of developing nosocomial pneumonia is higher in patients who are already hospitalized due to various medical conditions, surgeries, or use of medical devices like ventilators. The infection can be caused by different types of bacteria, viruses, or fungi present in the healthcare environment. Preventive measures, such as proper hand hygiene, infection control practices, and minimizing the use of invasive devices, are crucial in reducing the incidence of nosocomial pneumonia.

Correct Answer: B

Rationale: The Heimlich maneuver, also known as abdominal thrusts, is performed on a client to clear the airway if the client is choking and cannot speak or breathe after swallowing food. The maneuver involves applying upward pressure on the abdomen in an effort to forcefully expel the object blocking the airway. It is a crucial life-saving technique that can prevent the client from suffocating due to an obstructed airway. In cases of choking emergencies, the Heimlich maneuver should be administered promptly to effectively remove the obstruction and restore breathing.

Correct Answer: D

Rationale: At this age, building a tower involves fine motor skills and symbolic thinking.