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: Sexual dysfunction is a common SSRI side effect, as increased serotonin inhibits sexual arousal and orgasm. Monitoring is critical, as it affects adherence in depression treatment, requiring dose adjustments or alternative therapies, making it the priority side effect to assess.

Choice B reason: Hypotension is less common with SSRIs, though orthostatic changes may occur. Sexual dysfunction is more frequent, impacting quality of life and treatment adherence in depression, making it the priority to monitor, as it directly affects patient compliance and outcomes.

Choice C reason: Hyperglycemia is not a typical SSRI side effect, though metabolic changes are rare. Sexual dysfunction is a prevalent issue, reducing adherence in depression treatment, making it the priority to monitor, as it significantly impacts patient satisfaction and therapy continuation.

Choice D reason: Peripheral edema is rare with SSRIs, which primarily affect serotonin pathways. Sexual dysfunction is a common side effect, compromising adherence in depression management, making it the priority to monitor, as it directly influences treatment success and patient well-being.

A. Increase iron-rich foods B. Limit vitamin C intake C. Restrict green leafy vegetables D. Avoid whole grains

Correct Answer is A

Explanation

Choice A reason: Increasing iron-rich foods (e.g., red meat, spinach) corrects anemia by boosting hemoglobin synthesis, as iron is essential for red blood cell production. This addresses the underlying deficiency, improving oxygen transport, making it the priority dietary recommendation for anemia management.

Choice B reason: Limiting vitamin C is incorrect, as it enhances iron absorption, aiding anemia correction. Iron-rich foods are the priority, as they directly supply the deficient nutrient, improving hemoglobin levels, making vitamin C restriction counterproductive to effective anemia treatment.

Choice C reason: Restricting green leafy vegetables, which are iron-rich, worsens anemia. These foods (e.g., spinach) provide dietary iron, essential for hemoglobin synthesis. Increasing iron intake is the priority, as it corrects the deficiency, making vegetable restriction inappropriate for anemia.

Choice D reason: Avoiding whole grains is irrelevant, as they provide nutrients supporting overall health. Iron-rich foods directly address anemia by supplying iron for red blood cell production, making them the priority dietary recommendation over grain restrictions, which do not impact anemia correction.

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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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Naxlex Comprehensive Predictor Exams

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