A nurse is evaluating a client with suspected appendicitis. Which physical assessment finding is most indicative of this condition?

Rebound tenderness at McBurney’s point

Left lower quadrant pain

High-pitched bowel sounds

Soft, non-tender abdomen

Answer and Explanation

The Correct Answer is A

Choice A reason: Rebound tenderness at McBurney’s point (right lower quadrant) indicates peritoneal irritation, a hallmark of appendicitis. The inflamed appendix causes localized pain, exacerbated by pressure release due to peritoneal inflammation. This specific finding is highly suggestive of appendicitis, distinguishing it from other abdominal conditions.

Choice B reason: Left lower quadrant pain is not typical for appendicitis, which usually presents in the right lower quadrant due to the appendix’s anatomical location. Left-sided pain may suggest conditions like diverticulitis or colitis, but it does not align with the localized inflammation characteristic of appendicitis.

Choice C reason: High-pitched bowel sounds suggest increased peristalsis, as in early obstruction, but are not specific to appendicitis. Appendicitis may reduce bowel sounds due to peritoneal irritation. Rebound tenderness is a more direct indicator, as it reflects the localized inflammation and irritation of appendicitis.

Choice D reason: A soft, non-tender abdomen is inconsistent with appendicitis, which causes localized pain and tenderness due to inflammation. A non-tender abdomen suggests a normal or alternative condition, not appendicitis, where peritoneal irritation typically produces tenderness, especially at McBurney’s point, upon palpation or rebound.

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Correct Answer is A

Explanation

Choice A reason: Non-pharmacological options, like acupressure or aromatherapy, address nausea without medication risks. These interventions stimulate the parasympathetic nervous system or reduce gastric irritation, providing relief. Acting first with these methods is safe, effective, and aligns with holistic care, especially when the next antiemetic dose is not yet due.

Choice B reason: Notifying the provider after rounds delays intervention, as nausea requires prompt relief to prevent distress or vomiting. This approach does not address the client’s immediate need and may prolong discomfort. Non-pharmacological methods should be tried first, as they are within the nurse’s scope and can provide quicker relief.

Choice C reason: Discussing anesthesia’s role in nausea provides education but does not alleviate the client’s current symptoms. This cognitive approach addresses understanding, not immediate comfort. While education is valuable, the priority is relieving nausea, making non-pharmacological interventions a more appropriate first step in this scenario.

Choice D reason: Explaining that no other medications are ordered dismisses the client’s discomfort and does not provide relief. This approach fails to utilize the nurse’s scope to implement non-pharmacological interventions, which can effectively manage nausea. It may also reduce trust, as it does not address the client’s immediate needs.

A. Hypomagnesemia B. Hyponatremia C. Hyperchloremia D. Hypokalemia

Correct Answer is A

Explanation

Choice A reason: Hypomagnesemia, low magnesium (normal 1.7–2.2 mg/dL), is indicated by the 0.8 mEq/L value. Magnesium is vital for muscle, nerve, and cardiac function. Low levels can cause tremors, seizures, and arrhythmias. The other values (sodium, chloride, potassium) are within normal ranges, making hypomagnesemia the primary imbalance.

Choice B reason: Hyponatremia, low sodium (normal 135–145 mEq/L), is not indicated, as the sodium level is 140 mEq/L, within normal limits. Hyponatremia can cause neurological symptoms like confusion, but the lab values do not support this diagnosis, and magnesium imbalance is the clear abnormality.

Choice C reason: Hyperchloremia, high chloride (normal 98–106 mEq/L), is not present, as the chloride level is 107 mEq/L, just above normal and not clinically significant. Elevated chloride may occur in dehydration or renal issues, but the primary concern here is the significantly low magnesium level.

Choice D reason: Hypokalemia, low potassium (normal 3.5–5.0 mEq/L), is not indicated, as the potassium level is 3.6 mEq/L, within normal range. Hypokalemia causes muscle weakness and arrhythmias, but the lab values point to hypomagnesemia as the primary electrolyte imbalance in this case.

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A nurse is evaluating a client with suspected appendicitis. Which physical assessment finding is most indicative of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client continues to report nausea following surgery from the anesthesia. She has received an antiemetic, and the next dose is not due for another hour. What should the nurse do first?

Correct Answer is A

Explanation

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

Correct Answer is A

Explanation

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