A nurse is caring for a client who has appendicitis. Which of the following findings should the nurse identify as a manifestation of this condition? (Select all that apply.)
WBC count 22,000/mm2 (5,000 to 10,000/mm3)
Diarrhea
Rebound tenderness
Low-grade fever
Hyperactive bowel sounds
Correct Answer : A,C,D
A. WBC count 22,000/mm³ (5,000 to 10,000/mm³): Leukocytosis is a common finding in appendicitis due to the inflammatory and infectious process. A significantly elevated WBC count supports the diagnosis and indicates the body’s response to infection.
B. Diarrhea: Diarrhea is not a typical manifestation of appendicitis. Clients more commonly present with constipation or localized abdominal pain rather than frequent loose stools, so this finding is not characteristic.
C. Rebound tenderness: Rebound tenderness, especially in the right lower quadrant, is a classic sign of peritoneal irritation associated with appendicitis. Pain that increases when pressure is released is a key physical examination finding.
D. Low-grade fever: A low-grade fever often accompanies appendicitis due to the body’s inflammatory response. Fever typically develops as the condition progresses and can help differentiate appendicitis from other causes of abdominal pain.
E. Hyperactive bowel sounds: Hyperactive bowel sounds are more commonly associated with gastroenteritis or early intestinal obstruction. In appendicitis, bowel sounds are often normal or decreased, particularly if peritoneal irritation is present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instill normal saline drops to nares before meals: Saline drops are used to loosen nasal secretions in conditions like the common cold or bronchiolitis. They do not address epiglottitis and are not a primary intervention for this life-threatening airway condition.
B. Perform chest percussion and postural drainage twice per day: Chest physiotherapy is indicated for conditions with increased pulmonary secretions, such as cystic fibrosis or pneumonia. Epiglottitis primarily affects the upper airway, so these interventions are not appropriate.
C. Initiate droplet precautions: Epiglottitis is often caused by Haemophilus influenzae type b and can be transmitted via respiratory droplets. Implementing droplet precautions protects healthcare workers and other clients from infection while the child receives care.
D. Administer pancreatic enzymes with meals: Pancreatic enzyme replacement is used in conditions like cystic fibrosis to aid digestion. It is unrelated to epiglottitis and does not address the acute respiratory risk posed by airway inflammation.
Correct Answer is ["A","B","D","E"]
Explanation
A. Urine protein: The presence of 3+ protein in the urine is abnormal and indicates significant proteinuria, which is a key sign of preeclampsia. Monitoring protein levels is essential for detecting kidney involvement and assessing maternal and fetal risk.
B. Report of headache: A severe headache unrelieved by acetaminophen in a pregnant client with elevated blood pressure is a concerning symptom of preeclampsia. It can indicate cerebral involvement and increased risk for complications such as eclampsia or stroke.
D. Fetal activity: Decreased fetal movement is an important sign of potential fetal compromise. Reduced activity may indicate fetal distress or hypoxia, requiring prompt assessment and possible intervention.
E. Blood pressure: A blood pressure reading of 162/112 mm Hg is significantly elevated and meets criteria for severe preeclampsia. Hypertension during pregnancy can lead to maternal and fetal complications, making this a critical finding to address immediately.
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