Which of the following pieces of data is LEAST likely to support the nurse's suspicion that their client has acute appendicitis?

Is lying very still in a fetal position.

Reports "crampy abdominal pain which has now intensified and localized to one side.”.

Reports rhinitis and myalgias.

Didn't feel like eating breakfast.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Clients with acute appendicitis often lie still in a fetal position to reduce pain caused by movement. The fetal position helps decrease tension on the abdominal muscles, providing relief.

Choice B rationale

Initial pain in appendicitis is often crampy and diffuse but later localizes to the right lower quadrant (McBurney's point). The progression of pain from generalized to localized is typical in appendicitis.

Choice C rationale

Rhinitis (nasal inflammation) and myalgias (muscle pain) are symptoms more associated with viral infections like the flu, not acute appendicitis. These symptoms do not support a diagnosis of appendicitis.

Choice D rationale

A lack of appetite (anorexia) is common in clients with appendicitis due to the discomfort and inflammation in the abdomen, making this a supportive symptom.

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Correct Answer is D

Explanation

Choice A rationale

Pain relieved by eating food is more characteristic of duodenal ulcers rather than gastric ulcers. Gastric ulcers typically cause pain shortly after eating due to the stomach's exposure to gastric acid and food content.

Choice B rationale

Pain occurring at night can be associated with both duodenal and gastric ulcers. However, it is not as distinctive for gastric ulcers as the timing relative to meals.

Choice C rationale

Pain always on the left side is not a typical presentation for gastric ulcers, as the location can vary and is often associated with the mid-epigastric area rather than a specific side.

Choice D rationale

Pain occurring 30 minutes after eating is consistent with gastric ulcers. This timing reflects the direct irritation of the ulcerated gastric mucosa by the ingested food and gastric acid.

A. Fecal-smelling breath. B. Severe abdominal distention. C. Weakness, weight loss, and anorexia. D. High-pitched tinkling bowel sounds. E. Intense thirst.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Fecal-smelling breath is a symptom of small intestine obstruction due to bacterial fermentation of trapped food, which produces a foul odor that can be detected on the breath.

Choice B rationale

Severe abdominal distention occurs in small intestine obstructions because of the accumulation of gas and fluids proximal to the obstruction site, leading to a noticeable increase in abdominal girth.

Choice C rationale

Weakness, weight loss, and anorexia are more characteristic of chronic gastrointestinal conditions rather than acute small intestine obstruction. These symptoms develop over a longer period and are not acute manifestations.

Choice D rationale

High-pitched tinkling bowel sounds are a typical finding in small intestine obstruction. They occur due to increased peristaltic activity proximal to the obstruction site as the intestines attempt to move the obstructed contents.

Choice E rationale

Intense thirst is not a primary manifestation of small intestine obstruction. While dehydration can occur, it is not specific to small intestine obstruction and can be a result of many other conditions.

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Which of the following pieces of data is LEAST likely to support the nurse's suspicion that their client has acute appendicitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is recording data obtained from a client's admission assessment. Which notation is most consistent with the presence of a gastric ulcer? The client states that pain:

Correct Answer is D

Explanation

A nurse is assessing a client who has an obstruction in the small intestine. Clinical manifestations that the nurse would expect include: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

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