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 C
Explanation
Choice A rationale
Friction rub is not a typical complication of endocarditis. It is more commonly associated with pericarditis, which is inflammation of the pericardium.
Choice B rationale
Intermittent claudication is not a complication of endocarditis. It is typically associated with peripheral artery disease, which affects blood flow to the limbs.
Choice C rationale
Cardiac murmur is a common finding in endocarditis. The infection can cause damage to the heart valves, leading to abnormal heart sounds or murmurs.
Choice D rationale
Dependent rubor is not a complication of endocarditis. It is usually associated with peripheral artery disease and is characterized by redness of the lower extremities when they are in a dependent position.
Correct Answer is C
Explanation
Choice A rationale
A mesh-like device within the catheter that springs open is characteristic of a stent, not a balloon-tipped catheter used in PTCA. Stents are often used in conjunction with angioplasty to keep the artery open after the balloon has compressed the plaque.
Choice B rationale
While catheters can be used to take pressure measurements, this is not the primary function of the balloon-tipped catheter in PTCA. The main purpose of the balloon-tipped catheter is to compress the plaque against the artery wall to improve blood flow.
Choice C rationale
The balloon-tipped catheter in PTCA is used to compress the plaque against the coronary blood vessel wall. This process, known as balloon angioplasty, helps to widen the artery and improve blood flow to the heart.
Choice D rationale
Cutting away plaque with an embedded blade is a description of atherectomy, not PTCA. Atherectomy involves a different type of catheter designed to remove plaque from the artery wall.
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