The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Sudden onset of severe anxiety, fear, and concern.

Periumbilical pain localizing to right lower quadrant.

Diffuse abdominal pain with elevated neutrophil count.

Anorexia progressing to nausea, vomiting, and fever.

Answer and Explanation

The Correct Answer is B

A.   While anxiety and fear can accompany many medical conditions, they are not typically associated with appendicitis. Appendicitis is characterized by physical symptoms like pain and digestive disturbances rather than emotional symptoms.
B.   Periumbilical pain that shifts to the right lower quadrant is the classic presentation of appendicitis. As the inflammation progresses, pain tends to move from the mid-abdomen to the lower right abdomen, which supports a diagnosis of appendicitis.
C.   Diffuse abdominal pain is less specific and could indicate a variety of conditions. While an elevated neutrophil count can suggest infection or inflammation, the localized pain seen in appendicitis is a more distinguishing feature.
D.   These symptoms are also common in appendicitis, as it typically presents with loss of appetite, nausea, and fever. However, the hallmark symptom is localized pain, particularly in the right lower quadrant, making B a stronger indication.

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Correct Answer is ["B","C","D","E","F","G"]

Explanation

A. Brudzinski reflexes test is primarily used to assess for meningeal irritation, which is not directly related to stroke.
B. Muscle tone assessments help to identify abnormalities in motor function, which could indicate neurological damage. Given the patient’s history and the recent fall, muscle tone should be checked for any signs of weakness or spasticity.
C. This test evaluates the client’s balance and proprioception. It is a quick way to check for potential issues with the nervous system, such as ataxia or other motor impairments, which could be present in a client with a stroke.
D. Assessing the level of consciousness is critical in a neurological assessment to ensure that the client is oriented and alert, which is especially important after a fall or stroke-like symptoms.
E. Pupillary response is an essential part of a neurological exam. Checking the size and reactivity of the pupils helps to assess brainstem function and overall neurological health.
F. Cranial nerve function should be assessed to evaluate for signs of neurological deficits. In stroke patients, cranial nerve impairments can provide important diagnostic information.
G. The Glasgow Coma Scale (GCS) is a standard tool for assessing the level of consciousness and neurological status. It can provide valuable insights into the severity of a neurological condition, especially in post-fall or post-stroke patients.

A. Tenting noted in subclavicular area. B. Loss of skin elasticity in the hand. C. Skin is warm and dry. D. Thinning hair in the lower extremities.

Correct Answer is A

Explanation

A. Skin tenting is a sign of dehydration. It occurs when the skin, after being pinched, does not quickly return to its normal position. This is often seen in areas with loose skin such as the subclavicular region.
B. Loss of skin elasticity is a normal aging process and not specifically indicative of dehydration. It can be seen in older adults regardless of hydration status.
C. Warm and dry skin can be a sign of dehydration. Dehydration leads to reduced sweating, which can result in dry skin, and it may also increase the body temperature, making the skin feel warm.
D. Thinning hair, especially in the lower extremities, is typically associated with circulatory issues or aging. It is not a direct sign of dehydration.

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The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

Correct Answer is ["B","C","D","E","F","G"]

Explanation

When assessing an older adult client, which finding is most indicative of dehydration?

Correct Answer is A

Explanation

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

Patient Data Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.