A nurse is admitting a client who has suspected appendicitis. Which of the following findings is the nurse’s priority to report to the provider?
Distended, board-like abdomen
WBC count 15,000/mm³ (5,000 to 10,000/mm³)
Rebound tenderness over McBurney’s point
Temperature 37.3°C (99.1°F)
The Correct Answer is A
Choice A Reason:
A distended, board-like abdomen is a critical finding that can indicate peritonitis, a severe complication of appendicitis. Peritonitis occurs when the appendix ruptures, leading to infection spreading throughout the abdominal cavity. This condition requires immediate medical intervention to prevent further complications and potential sepsis.
Choice B Reason:
A WBC count of 15,000/mm³ is elevated and suggests an infection, which is common in appendicitis. However, it is not as immediately critical as signs of peritonitis. Elevated WBC counts are expected in cases of appendicitis but do not necessarily indicate a life-threatening emergency.
Choice C Reason:
Rebound tenderness over McBurney’s point is a classic sign of appendicitis and indicates localized inflammation. While it is an important diagnostic sign, it does not require immediate reporting compared to signs of peritonitis.
Choice D Reason:
A temperature of 37.3°C (99.1°F) is only slightly elevated and does not indicate a severe infection or complication. Fever is a common symptom of appendicitis but is not as critical as a distended, board-like abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
Apply an ice pack directly to the affected area. This statement is incorrect. Applying ice to a snake bite can cause more harm than good. Ice can restrict blood flow and potentially increase tissue damage. The recommended approach is to keep the bite area still and at or below heart level to slow the spread of venom.
Choice B Reason
Immobilize the affected extremity with a splint. This is the correct intervention. Immobilizing the affected limb helps to slow the spread of venom by reducing movement. Keeping the limb still and using a splint can prevent the venom from circulating more rapidly through the body.
Choice C Reason
Place a tourniquet above and below the affected area. This statement is incorrect. Using a tourniquet is not recommended for snake bites as it can cause severe damage to the affected limb by cutting off blood flow completely. This can lead to tissue death and other complications.
Choice D Reason
Elevate the affected extremity. This statement is incorrect. Elevating the limb can increase the spread of venom. The affected limb should be kept at or below heart level to slow the venom’s spread.
Correct Answer is D
Explanation
Choice A Reason:
The statement that “Your provider will use your digital rectal examination to perform the test” is incorrect. A fecal occult blood test (FOBT) typically involves collecting stool samples at home over several days, not during a digital rectal examination. The samples are then sent to a lab for analysis to detect hidden blood in the stool.
Choice B Reason:
The statement that “Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel” is also incorrect. There is no need for a stimulant laxative before an FOBT. The test requires normal bowel movements to detect any hidden blood in the stool.
Choice C Reason:
The recommendation to “begin annual fecal occult blood testing for colorectal cancer screening at 40 years old” is not accurate. Current guidelines generally recommend starting colorectal cancer screening at age 45 for individuals at average risk. However, those with higher risk factors may need to start earlier, based on their healthcare provider’s advice.
Choice D Reason:
The statement “You should avoid taking corticosteroids prior to testing” is correct. Certain medications, including corticosteroids, can cause gastrointestinal bleeding, which may lead to false-positive results in an FOBT. Therefore, it is important to avoid these medications before the test, as advised by a healthcare provider.
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