The nurse is assessing a client who reports abdominal pain. Which of the following findings should the nurse identify as a possible indication of appendicitis?

Pain relieved by eating

Pain radiating to the back

Pain at McBurney’s point

Pain worsened by deep breathing

Answer and Explanation

The Correct Answer is C

Choice A reason: Pain relieved by eating is not typical of appendicitis, which often worsens with food intake due to inflammation. This suggests a gastrointestinal issue like gastritis, making it incorrect for appendicitis.

Choice B reason: Pain radiating to the back is more associated with conditions like pancreatitis or aortic aneurysm. Appendicitis pain is localized or radiates to the right lower quadrant, making this incorrect.

Choice C reason: Pain at McBurney’s point (right lower quadrant, midway between umbilicus and iliac crest) is a classic appendicitis sign due to localized inflammation. This specificity makes it the correct finding.

Choice D reason: Pain worsened by deep breathing may occur in pleuritic or abdominal conditions but is not specific to appendicitis. McBurney’s point pain is more diagnostic, making this less indicative.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Pain medication administration does not directly contribute to dehiscence, which results from mechanical stress or poor healing. While pain control is important, it is not a primary risk factor compared to nutrition, obesity, or infection, making this incorrect.

Choice B reason: Poor nutritional state is a risk factor for dehiscence, as inadequate protein and vitamins impair collagen synthesis, weakening wound closure. Malnutrition delays healing, increasing the risk of incision separation under stress, making this a correct factor to include.

Choice C reason: Obesity increases dehiscence risk due to excessive tension on incisions from adipose tissue, poor vascularity, and higher infection rates. This mechanical and physiological stress compromises wound integrity, making it a correct factor to include in teaching.

Choice D reason: Altered mental state is not a direct risk factor for dehiscence, though it may affect compliance with activity restrictions. Physical factors like infection or obesity have a stronger impact on wound healing, making this incorrect.

Choice E reason: Wound infection is a key risk factor for dehiscence, as bacterial activity weakens tissue and disrupts healing, causing incision breakdown. These compromises wound integrity, making it a critical factor to include in teaching about surgical complications.

A. Minimize skin exposure to moisture B. Use pillows to keep heels off the bed surface C. Massage over erythematous bony prominences D. Keep the client’s skin dry with powder E. Implement turning schedule every 4 hours

Correct Answer is ["A","B"]

Explanation

Choice A reason: Minimizing moisture prevents maceration, which weakens skin and increases breakdown risk. In paralyzed patients, incontinence or sweating exacerbates pressure ulcers, making moisture control essential for skin integrity.

Choice B reason: Using pillows to elevate heels reduces pressure on bony prominences, common ulcer sites. Offloading pressure prevents tissue ischemia, making this an effective intervention for skin breakdown prevention.

Choice C reason: Massaging erythematous bony prominences risks tissue damage, as it increases pressure on compromised areas. Gentle repositioning is preferred, making this an incorrect action for preventing skin breakdown.

Choice D reason: Powder can cake and irritate skin, increasing breakdown risk, especially in moist areas. Proper drying and barrier creams are safer, making powder use an incorrect intervention for skin protection.

Choice E reason: Turning every 4 hours is insufficient; paralyzed patients require repositioning every 2 hours to prevent pressure ulcers. This frequency is too low, making it an incorrect choice for effective prevention.

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The nurse is assessing a client who reports abdominal pain. Which of the following findings should the nurse identify as a possible indication of appendicitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for surgical clients who have surgical incisions. Which of the following should the nurse include? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

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