During a gastrointestinal assessment, the nurse detects rebound tenderness in the right lower quadrant (RLQ). What does this finding most likely indicate?
Appendicitis
Pancreatitis
Cholecystitis
Diverticulitis
The Correct Answer is D
Choice A reason: Rebound tenderness in the right lower quadrant, often at McBurney’s point, is a hallmark of appendicitis, indicating peritoneal irritation from an inflamed appendix. This sign, elicited by releasing pressure during palpation, suggests localized inflammation, requiring urgent surgical evaluation to prevent rupture and peritonitis.
Choice B reason: Pancreatitis typically presents with epigastric or left upper quadrant pain, radiating to the back, not right lower quadrant rebound tenderness. It involves pancreatic inflammation, often due to gallstones or alcohol, and is assessed via serum amylase and lipase, not RLQ findings, making this incorrect.
Choice C reason: Cholecystitis causes right upper quadrant pain and tenderness, often with Murphy’s sign, due to gallbladder inflammation. Rebound tenderness in the right lower quadrant is not characteristic, as cholecystitis affects the upper abdomen, making this choice misaligned with the clinical finding.
Choice D reason: Diverticulitis typically causes left lower quadrant pain, as diverticula are common in the sigmoid colon. Right lower quadrant rebound tenderness is not a typical finding, as it suggests appendicitis instead, making this choice incorrect for the described gastrointestinal assessment finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The Snellen chart tests visual acuity (cranial nerve II), not balance, which is assessed by cranial nerve VIII via the Romberg test. Misidentifying this risks incorrect neurological evaluation, potentially missing vestibular deficits, critical for diagnosing balance disorders like vertigo or labyrinthitis in patients with cranial nerve issues.
Choice B reason: The Rinne test assesses hearing (cranial nerve VIII) by comparing air and bone conduction, not balance, which the Romberg test evaluates. Assuming Rinne tests balance misguides assessment, risking oversight of vestibular dysfunction, essential for diagnosing conditions affecting equilibrium in patients with suspected nerve VIII issues.
Choice C reason: The Weber test evaluates hearing lateralization (cranial nerve VIII), not balance, assessed by the Romberg test. Misidentifying Weber risks missing balance deficits, potentially delaying diagnosis of vestibular disorders like Meniere’s disease, critical for managing symptoms and preventing falls in patients with cranial nerve VIII dysfunction.
Choice D reason: The Romberg test assesses balance (cranial nerve VIII’s vestibular component) by evaluating posture with eyes closed, detecting vestibular or proprioceptive deficits. It’s critical for diagnosing balance disorders, guiding interventions like vestibular therapy, essential for preventing falls and managing conditions affecting equilibrium in patients with nerve VIII issues.
Correct Answer is D
Explanation
Choice A reason: A blood pressure of 90/80 mmHg is below normal, indicating hypotension, especially with a low systolic value. Normal adult blood pressure, per guidelines, is around 120/80 mmHg. Low readings may suggest dehydration or cardiovascular issues, requiring evaluation, making this choice incorrect.
Choice B reason: A reading of 95/60 mmHg is hypotensive, with both systolic and diastolic values below normal ranges. Normal blood pressure is approximately 120/80 mmHg, per American Heart Association guidelines. Such low readings may indicate shock or autonomic dysfunction, rendering this choice incorrect.
Choice C reason: A blood pressure of 180/60 mmHg is abnormal, with elevated systolic pressure indicating hypertension and a low diastolic value suggesting possible aortic regurgitation. Normal blood pressure is 120/80 mmHg. This reading requires urgent assessment, making it an incorrect choice for normal adult values.
Choice D reason: A blood pressure of 120/80 mmHg is considered normal for adults, per current guidelines like those from the American Heart Association. It reflects balanced systolic and diastolic pressures, indicating healthy cardiovascular function without signs of hypertension or hypotension, making it the correct choice.
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