The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect?

Severe, steady right lower quadrant pain

Abdominal pain associated with nausea and vomiting

Marked peristalsis and hyperactive bowel sounds

Abdominal pain that increases with knee flexion

Answer and Explanation

The Correct Answer is A

A. Severe, steady pain in the right lower quadrant (typically at McBurney’s point) is a classic sign of appendicitis, often indicating localized inflammation.
B. While nausea and vomiting may occur, they are nonspecific symptoms and not diagnostic by themselves.
C. Marked peristalsis and hyperactive bowel sounds are not characteristic of appendicitis; bowel sounds may actually be diminished.
D. Abdominal pain with hip extension (not knee flexion) may increase in cases of appendicitis due to irritation of the psoas muscle, but knee flexion does not typically worsen the pain.

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Correct Answer is C

Explanation

A. Enzyme capsules can be opened and the contents sprinkled on soft, acidic foods like applesauce to aid in swallowing.

B. Wiping the lips helps prevent skin irritation from the enzymes.

C. This indicates a need for further teaching. Enzymes should be taken with meals or immediately before eating—not after—so they can mix properly with food in the digestive tract.

D. Enzyme powder should not be mixed with protein-containing foods or liquids, as it may break down the proteins before ingestion.

A. "Elevate the head of your bed by 18 inches." B. "Avoid snacking between meals." C. "Limit foods that are high in fiber." D. "Avoid eating 2 to 3 hours before bedtime."

Correct Answer is D

Explanation

A. While elevating the head of the bed is helpful, 6 to 8 inches is the recommended range—not 18 inches, which is excessive and impractical.

B. Avoiding snacking is not a standard recommendation for GERD management; small, frequent meals are often encouraged.

C. High-fiber foods are generally beneficial and not contraindicated in GERD.

D. Avoiding food 2 to 3 hours before bedtime helps prevent nighttime reflux by reducing stomach contents during sleep, making this a key lifestyle modification for GERD.

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The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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