A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
I have no appetite.
The pain hurts so much it is making me nauseous.
When I position myself on my right side, it makes the pain worse.
The pain seems to be gone now.
The Correct Answer is D
Choice A rationale
Loss of appetite is a common symptom of appendicitis due to the inflammation and irritation of the gastrointestinal tract. This symptom alone does not indicate an immediate need for intervention.
Choice B rationale
Nausea and vomiting are also common symptoms of appendicitis. The pain and inflammation can stimulate the vomiting center in the brain, leading to nausea. This symptom, while uncomfortable, does not require immediate intervention.
Choice C rationale
Pain that worsens with movement, such as positioning on the right side, is typical of appendicitis. This is due to the irritation of the peritoneum and the inflamed appendix. This symptom is expected and does not require immediate intervention.
Choice D rationale
The sudden disappearance of pain in a patient with appendicitis can indicate a rupture of the appendix. This is a medical emergency as it can lead to peritonitis, a severe and potentially life- threatening infection of the abdominal cavity. Immediate intervention is required to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Weak pedal pulses indicate vascular compromise, which is a complication of Buck’s traction. This can be caused by pressure on the tissues of the leg.
Choice B rationale
Complaints of leg discomfort are expected due to the traction and do not indicate a complication.
Choice C rationale
Toes that are warm and demonstrate brisk capillary refill are normal findings and do not indicate a complication.
Choice D rationale
Drainage at the pin sites is more relevant to skeletal traction, not Buck’s traction.
Correct Answer is C
Explanation
Choice A rationale
While a JP drain can help limit bleeding and clots, its primary purpose is not to control bleeding. It is more focused on preventing fluid accumulation.
Choice B rationale
A JP drain does not eliminate the need for wound irrigations. Wound irrigations may still be necessary to clean the wound and prevent infection.
Choice C rationale
The primary purpose of a Jackson-Pratt (JP) drain is to prevent drainage from accumulating in the wound. By removing excess fluid, the JP drain helps reduce the risk of infection and promotes faster healing.
Choice D rationale
A JP drain is not used for medication administration. It is specifically designed to remove fluid from the surgical site.
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