A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)
Left upper quadrant
Right upper quadrant
Right lower quadrant
Left upper quadrant
The Correct Answer is C
Choice A reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice B reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice C reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice D reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
This statement is not directly related to the client's use of bisacodyl tablets. It addresses irregular bowel movements in a general sense.
Choice B reason:
Decreasing fiber intake is not a recommended approach, especially for an older adult who may benefit from a balanced diet with adequate fiber.
Choice C reason:
This is the correct answer. Excessive use of laxatives, including bisacodyl, can lead to electrolyte imbalances. Bisacodyl is a stimulant laxative that can cause excessive fluid loss and potentially
disrupt electrolyte levels.
Choice D reason:
While chronic use of laxatives can lead to various complications, including potential harm to the rectal mucosa, this choice is not the most appropriate response to the client's current situation.
Correct Answer is B
Explanation
Choice A reason:
While thirst can be a sign of dehydration, it is not specific to recurrence of a GI bleed.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of a GI bleed and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to recurrence of a GI bleed.
Choice D reason:
Tarry, foul-smelling stools are indicative of melena, which is a sign of a GI bleed. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
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