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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Documenting the finding is important to ensure proper record-keeping, especially in clients with dark pigmented skin, where some variations in skin tone may be normal.
B. Asking about antibiotics is unnecessary unless there's suspicion of a drug-induced reaction or side effect.
C. While use of irritating chemicals could cause changes, this scenario does not directly suggest that as the cause.
D. Referral to a dermatologist is not required without further investigation to determine if the discoloration is concerning.

A. Observe for any facial asymmetry. B. Determine the response to stimuli. C. Assess for a positive Romberg sign. D. Check the pupillary response to light.

Correct Answer is B

Explanation

A. Facial asymmetry may indicate neurological issues, but it does not directly assess the stuporous state.
B. A stuporous state is characterized by a reduced level of consciousness, and the nurse should assess
the client’s response to stimuli to confirm the report of stupor.
C. A positive Romberg sign indicates a balance issue, but it is not directly related to confirming a stuporous state.
D. While pupillary response is important, it does not provide sufficient information to confirm a stuporous state without assessing responsiveness to stimuli.

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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

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Correct Answer is B

Explanation

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