A nurse collecting data from a client who has manifestations of appendicitis. Where should the nurse palpate to monitor for pain at McBurney's point? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
The Correct Answer is "{\"xRanges\":[83.109375,104.109375],\"yRanges\":[119.5,140.5]}"
Draw an imaginary line connecting the ASIS to the umbilicus.
McBurney's point is located one-third of the distance along this line, starting from the ASIS and moving towards the umbilicus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I'm tired and want to take a nap." Common in sick children and not necessarily concerning in this context.
B. "I am scared and I want to go home." Emotional response, typical in children facing surgery.
C. "I am hungry and thirsty." Normal sensations and not indicative of the severity of the condition.
D. "My belly doesn't hurt anymore." This statement suggests potential rupture or perforation of the appendix, which can lead to peritonitis and is a surgical emergency. A sudden relief of pain can indicate a worsening condition rather than improvement.
Correct Answer is B
Explanation
A. Rigid abdomen: A rigid abdomen is not typically associated with Hirschsprung disease unless there is severe obstruction and distension.
B. Ribbonlike, foul-smelling stools: Hirschsprung disease causes obstruction of the colon, leading to constipation and ribbonlike, foul-smelling stools proximal to the affected segment.
C. Projectile vomiting: Projectile vomiting is not typically associated with Hirschsprung disease but may occur in other conditions causing bowel obstruction.
D. Chronic hunger: Chronic hunger is not a typical finding in Hirschsprung disease and is more indicative of metabolic or endocrine disorders.
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