A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect?(Select all that apply.).
Elevated WBC Count.
Elevated amylase level.
Rebound tenderness.
Ascites.
Anorexia.
Correct Answer : A,C,E
Choice A rationale:
An elevated white blood cell (WBC) count is an expected manifestation in a client with suspected appendicitis. Inflammation in the appendix leads to an immune response, causing an increase in WBC count.
Choice B rationale:
Elevated amylase level is not typically associated with appendicitis. Elevated amylase is more commonly seen in pancreatitis, not appendicitis.
Choice C rationale:
Rebound tenderness, which refers to increased pain when pressure is released rather than applied, is a classic symptom of appendicitis. The nurse should expect to find rebound tenderness during the abdominal assessment.
Choice D rationale:
Ascites are not a common manifestation of appendicitis. Ascites is the accumulation of fluid in the abdominal cavity and are more commonly seen in liver cirrhosis and certain other conditions, but not in appendicitis.
Choice E rationale:
Anorexia, or loss of appetite, can be seen in clients with appendicitis due to the inflammation and discomfort in the abdominal region.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D. The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services:
Rationale:
A) The nurse files an incident report regarding a medication error:
Filing an incident report about a medication error is an important action for ensuring safety and quality improvement within the healthcare setting. However, it is primarily a procedural and administrative task rather than an act of direct advocacy for an individual client's needs or rights.
B) The nurse provides wound care to a client at the time promised to the client:
Providing wound care as promised demonstrates reliability and adherence to care plans, which is essential for trust and effective nursing practice. While this action shows respect for the client's needs and preferences, it does not specifically address the broader role of advocacy, which often involves intervening on behalf of the client's best interests in more complex situations.
C) The nurse declines to inform a client's neighbor about the client's prognosis:
Maintaining client confidentiality by not sharing private information with unauthorized individuals is a fundamental aspect of ethical nursing practice. This action protects the client's privacy but is more about upholding legal and ethical standards than actively advocating for the client's overall well-being or specific needs.
D) The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services:
Referring a client with chronic obstructive pulmonary disease (COPD) to palliative care services exemplifies client advocacy. This action recognizes the client's need for comprehensive support, focusing on improving quality of life, managing symptoms, and providing holistic care. It involves proactive steps to address the client's complex health needs, ensuring they receive appropriate and compassionate care beyond standard medical treatment.
Correct Answer is C
Explanation
Choice A rationale:
A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.
Choice B rationale:
A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.
Choice C rationale:
A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.
Choice D rationale:
A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.
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