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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Unilateral joint involvement is not typical of rheumatoid arthritis. This condition usually affects joints symmetrically, meaning both sides of the body are involved. Rheumatoid arthritis is an autoimmune disorder where the immune system mistakenly attacks the synovium, leading to inflammation and joint damage.

Choice B rationale

Ulnar deviation is a common finding in rheumatoid arthritis. It occurs due to chronic inflammation and damage to the joints, particularly in the hands. The fingers may deviate towards the ulnar side (the side of the little finger) due to the weakening of the ligaments and tendons.

Choice C rationale

Decreased sedimentation rate is not a typical finding in rheumatoid arthritis. In fact, the erythrocyte sedimentation rate (ESR) is usually elevated in this condition due to the ongoing inflammation. ESR is a marker of inflammation and is used to monitor disease activity.

Choice D rationale

Fractures of the spine are not a common finding in rheumatoid arthritis. While osteoporosis can be a complication of rheumatoid arthritis, leading to an increased risk of fractures, the spine is not typically the primary site of joint involvement in this condition.

A. “I will lie on my left side to sleep at night.”. B. “I will lie on my right side to sleep at night.”. C. “I will sleep on my back with my head flat.”. D. “I will sleep on my stomach with my head flat.”.

Correct Answer is A

Explanation

Choice A rationale

Lying on the left side can help minimize the effects of reflux during sleep. This position helps keep the stomach contents lower than the esophagus, reducing the likelihood of acid reflux.

Choice B rationale

Lying on the right side can increase the risk of acid reflux. This position allows the stomach contents to flow more easily into the esophagus, exacerbating reflux symptoms.

Choice C rationale

Sleeping on the back with the head flat can worsen reflux symptoms. This position allows stomach acid to flow back into the esophagus more easily, increasing the risk of reflux.

Choice D rationale

Sleeping on the stomach with the head flat is not recommended for clients with GERD. This position can increase pressure on the stomach, promoting acid reflux into the esophagus.

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A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?

Correct Answer is A

Explanation

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

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