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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hip surgery involves invasive procedures, increasing infection risk due to surgical wounds, immobility, and potential hardware. This patient faces higher risk than others, making it the correct choice.
Choice B reason: Heart problem stabilization may involve catheters, but surgical wounds pose a greater infection risk. Cardiac patients are less prone to immediate infection unless invasive devices are present, making this less likely.
Choice C reason: Dehydration weakens immunity but is less directly linked to infection than surgical wounds. Hydration correction reduces risk, making this patient less at risk than the surgical patient.
Choice D reason: Chest pain observation typically involves non-invasive monitoring, with lower infection risk than surgery. Without invasive procedures, this patient is less susceptible, making this incorrect.
Correct Answer is B
Explanation
Choice A reason: Asking the client to state their name is useful but less reliable than a wristband, as confusion or language barriers may lead to errors. Wristbands provide objective identification, making this secondary.
Choice B reason: Checking the client’s wristband is the most reliable method, as it contains verified identifiers (name, medical record number). This ensures accurate identification, making it the correct action for verification.
Choice C reason: Asking a family member is unreliable, as they may be mistaken or absent. Wristbands provide standardized, objective identification, making family confirmation inappropriate and less accurate.
Choice D reason: Comparing the client’s face to a photo is useful but not always available or reliable, especially in emergencies. Wristband verification is standard and objective, making this a secondary method.
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