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 B

Explanation

Choice A reason: Arterial blood gases assess oxygenation and acid-base balance, critical for diagnosing respiratory distress severity. However, this diagnostic measure does not immediately relieve airway obstruction. Clearing secretions is prioritized to restore ventilation, as hypoxia can rapidly cause tissue damage or cardiac arrest in acute respiratory distress.

Choice B reason: Suctioning removes airway secretions, directly addressing breathing difficulty. Secretions obstruct airways, reducing oxygen delivery to alveoli and impairing gas exchange. Immediate suctioning restores patency, enhances ventilation, and prevents hypoxia, making it the priority intervention to stabilize the client’s respiratory function in acute distress.

Choice C reason: PRN analgesia addresses pain, which is not indicated as the primary issue. Pain relief does not resolve airway obstruction or improve breathing. Administering analgesia prematurely could mask respiratory symptoms, delaying critical airway management and potentially worsening hypoxia by neglecting the underlying obstruction.

Choice D reason: An antipyretic reduces fever, improving comfort but not addressing breathing difficulty. Fever is secondary, and treating it does not restore airway patency or oxygenation. Airway management is prioritized in respiratory distress to prevent hypoxia and ensure effective gas exchange before managing fever symptoms.

A. Until a smaller angle can be restored B. For long-term control of normal eye pressure C. Until the excess pressure is reduced D. For long-term control of pain and swelling

Correct Answer is B

Explanation

Choice A reason: Open-angle glaucoma involves chronic optic nerve damage due to impaired aqueous humor drainage, not a reversible “angle” change. Medications reduce intraocular pressure but cannot restore anatomical angles. This response is inaccurate, as the condition requires lifelong management to prevent further nerve damage and vision loss.

Choice B reason: Open-angle glaucoma requires lifelong medication to maintain normal intraocular pressure, preventing optic nerve damage. Medications like prostaglandin analogs or beta-blockers enhance aqueous humor outflow or reduce production, controlling pressure long-term. This is the accurate response, as sustained pressure management is essential to preserve vision in chronic glaucoma.

Choice C reason: Reducing excess pressure is a goal of glaucoma treatment, but open-angle glaucoma is chronic, requiring ongoing medication even after pressure is lowered. This response is incomplete, as it suggests a temporary treatment, whereas lifelong therapy is needed to prevent pressure spikes and progressive optic nerve damage.

Choice D reason: Open-angle glaucoma is typically painless and not associated with swelling. Medications target intraocular pressure, not pain or inflammation. This response is inaccurate, as it misaligns with the pathophysiology of glaucoma, which involves optic nerve damage from pressure, not inflammatory or painful symptoms.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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