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 ["72"]
Explanation
Step 1 is to calculate the burned area using the Rule of Nines. The Rule of Nines assigns percentages to different body areas to estimate the total body surface area (TBSA) affected by burns. For example, each arm is 9%, each leg is 18%, the front and back of the torso are each 18%, and the head is 9%.
Step 1: Calculate the burned area. If the client has burns on the front and back of both legs, the calculation would be: (18% + 18%) + (18% + 18%) = 72%
The final calculated answer is 72%.
Correct Answer is C
Explanation
Choice A rationale
Fever usually accompanies myocardial infarction. This statement is incorrect. While fever can occur with myocardial infarction, it is not a common or primary symptom. Acetaminophen is not prescribed for this reason.
Choice B rationale
Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does. This statement is correct but not the reason for prescribing acetaminophen before nitrates. Acetaminophen is chosen for its analgesic properties without affecting platelet function.
Choice C rationale
Headache is a common side effect of nitrates. This statement is correct. Nitrates can cause vasodilation, leading to headaches. Acetaminophen is prescribed to manage this common side effect.
Choice D rationale
Acetaminophen potentiates the therapeutic effect of nitrates. This statement is incorrect. Acetaminophen does not enhance the therapeutic effects of nitrates; it is used to manage side effects like headaches.
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