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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A capillary refill of less than 1 second is a normal finding and indicates adequate peripheral perfusion. It is not a cause for concern in this postoperative client.
Choice B rationale:
The presence of a pulse deficit should be reported to the provider because it suggests a discrepancy between the apical and radial pulses, indicating potential cardiovascular compromise or inadequate arterial perfusion.
Choice C rationale:
A systolic blood pressure 10 points lower than before surgery can be a normal response to anesthesia or surgery and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
Choice D rationale:
Pulse oximetry at 96% is within the normal range for oxygen saturation and does not warrant immediate reporting. However, if the client is experiencing respiratory distress or other concerning symptoms, it should be addressed promptly.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.
Choice B rationale:
Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.
Choice C rationale:
Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.
Choice D rationale:
There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.
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