The nurse is assessing a client with suspected appendicitis. Which finding is most indicative of this condition?

Rebound tenderness in the right lower quadrant

Diffuse abdominal pain

Decreased bowel sounds

Elevated blood pressure

Answer and Explanation

The Correct Answer is A

Choice A reason: Rebound tenderness in the right lower quadrant (McBurney’s point) is a hallmark of appendicitis, indicating peritoneal irritation from an inflamed appendix. This localized pain, elicited on palpation release, is highly specific, guiding urgent surgical evaluation to prevent rupture and peritonitis.

Choice B reason: Diffuse abdominal pain is nonspecific and occurs in various conditions, not uniquely appendicitis, which typically presents with localized right lower quadrant pain. Rebound tenderness is more diagnostic, as it directly reflects appendiceal inflammation, making it the priority finding.

Choice C reason: Decreased bowel sounds may occur in appendicitis due to ileus but are nonspecific, seen in other abdominal conditions. Rebound tenderness is more indicative, as it localizes to the appendix, confirming peritoneal irritation, critical for diagnosing acute appendicitis.

Choice D reason: Elevated blood pressure is not specific to appendicitis and may reflect pain or stress. Rebound tenderness directly indicates appendiceal inflammation, making it the most reliable finding, as it guides diagnosis and urgent intervention to prevent complications like perforation.

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Correct Answer is A

Explanation

Choice A reason: Rinsing the mouth after using a corticosteroid inhaler prevents oral candidiasis, a common side effect from residual steroid deposition. This ensures safe asthma management, as fungal infections compromise adherence and health, making it the priority teaching point for proper inhaler use.

Choice B reason: Using the inhaler only during asthma attacks applies to rescue inhalers, not maintenance corticosteroids, which are used daily. This is incorrect, as rinsing the mouth is essential for corticosteroid inhalers to prevent oral thrush, ensuring safe and effective asthma control.

Choice C reason: Storing inhalers in a refrigerator is unnecessary and may degrade some medications. Room-temperature storage is standard. Rinsing the mouth after corticosteroid inhaler use is critical to prevent oral candidiasis, making it the priority teaching point for asthma management.

Choice D reason: Shaking the inhaler only once may be insufficient for proper aerosolization in some devices. Rinsing the mouth after corticosteroid inhaler use is the priority, as it prevents oral thrush, a significant side effect, ensuring safe and consistent asthma therapy.

A. Hemoglobin B. Glucose C. Total protein D. Sodium

Correct Answer is A

Explanation

Choice A reason: Diclofenac, an NSAID, can cause gastrointestinal bleeding, leading to anemia. Pale appearance and fatigue suggest blood loss. Reviewing hemoglobin levels is critical to confirm anemia, as low hemoglobin impairs oxygen delivery, exacerbating fatigue and requiring immediate intervention to address potential bleeding.

Choice B reason: Glucose levels are unrelated to diclofenac’s common side effects. Fatigue may occur in hypoglycemia, but diclofenac does not typically affect glucose metabolism. Pale appearance and fatigue are more indicative of anemia from NSAID-related bleeding, making hemoglobin a more urgent lab value to review.

Choice C reason: Total protein levels reflect nutritional status or liver function but are not directly linked to diclofenac’s side effects. Fatigue and pallor suggest anemia from gastrointestinal bleeding, a known NSAID risk. Hemoglobin is more critical to assess, as it directly correlates with the client’s symptoms.

Choice D reason: Sodium levels influence fluid balance but are not typically altered by diclofenac. Fatigue and pallor point to anemia from potential bleeding, not electrolyte imbalance. Hemoglobin review is prioritized, as diclofenac’s gastrointestinal side effects are more likely to cause blood loss than sodium disturbances.

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The nurse is assessing a client with suspected appendicitis. Which finding is most indicative of this condition?

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