Which findings in a routine health assessment would the nurse recognize as part of the CAUTION acronym? (Select All that Apply.)

Rationale:

A. Scheduling serological testing for Lyme disease may be part of the diagnostic process, but early testing is often unreliable because antibodies may not be detectable in the first few weeks after infection. Waiting for test results can delay treatment and increase the risk of complications.

B. Assessing for neurological involvement, such as facial palsy, is important in later stages of Lyme disease. While the nurse should monitor for these signs, it is not the immediate priority in a client with early localized disease and a characteristic rash.

C. Administering a prescribed dose of doxycycline is the most appropriate initial action. Early antibiotic treatment for Lyme disease, especially when a bull’s-eye rash (erythema migrans) is present, is critical to prevent progression to more serious systemic manifestations, including neurological, cardiac, or musculoskeletal complications. Prompt initiation of therapy is more important than waiting for confirmatory testing.

D. Initiating a discussion about safe hiking practices is valuable for health promotion and prevention, but it does not address the client’s immediate need for treatment. Education can be provided after initiating therapy.

Rationale:

A. Dull pain in the left upper quadrant is not indicative of appendicitis. Appendicitis typically begins as periumbilical or generalized abdominal pain, which later localizes to the right lower quadrant (RLQ). Left-sided pain is more commonly associated with conditions such as diverticulitis, splenic issues, or renal colic.

B. Rebound tenderness at McBurney’s point is a classic and highly suggestive finding for appendicitis. McBurney’s point is located one-third of the distance from the anterior superior iliac spine to the umbilicus. Tenderness at this point, especially with rebound (pain when pressure is released), indicates peritoneal irritation caused by inflammation of the appendix. This is considered a hallmark physical examination finding for acute appendicitis.

C. Hyperactive bowel sounds are not a specific indicator of appendicitis. While bowel sounds can vary in appendicitis, patients often present with normal or decreased bowel sounds due to localized inflammation or early paralytic ileus. Hyperactive sounds are more typical in gastroenteritis or early obstruction.

D. Pain relief when the right leg is flexed is not characteristic of appendicitis. In fact, certain maneuvers, like the psoas sign (pain on passive extension of the right hip) or obturator sign (pain on internal rotation of the flexed right hip), may exacerbate RLQ pain, but flexing the leg to relieve pain is not a diagnostic feature.