A nurse is caring for a 24-year-old female client in the emergency department (ED).
What is the most likely diagnosis for this client, based on the history, physical exam, and diagnostic results?
Acute appendicitis
Ectopic pregnancy
Ovarian cyst rupture
Acute gastritis
The Correct Answer is A
Choice A rationale: Acute appendicitis is most likely based on the history of sudden onset of severe abdominal pain localized to the right lower quadrant, nausea, vomiting with green bile, and tenderness on physical examination. The ultrasound findings of right lower quadrant tenderness further support this diagnosis. The client's vital signs, including tachycardia and tachypnea, are consistent with the stress and pain caused by acute appendicitis.
Choice B rationale: Ectopic pregnancy is less likely as the client has a negative pregnancy test and reports regular menstrual cycles with her last period occurring one week ago. Additionally, her symptoms are more typical of appendicitis.
Choice C rationale: Ovarian cyst rupture would typically present with sudden onset of pelvic pain, often associated with menstrual irregularities or a history of ovarian cysts. However, the client's presentation and diagnostic results strongly point towards acute appendicitis.
Choice D rationale: Acute gastritis generally presents with epigastric pain, nausea, and vomiting. However, the localization of pain to the right lower quadrant and the ultrasound findings make appendicitis a more likely diagnosis in this case.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Measuring and discarding residual gastric contents before feeding is generally avoided in infants because it can disrupt gastrointestinal function and increase the risk of aspiration. Instead, monitoring for signs of intolerance or high residuals through clinical observation is preferred.
Choice B rationale
Using the syringe plunger to push formula at a rate of 5 mL per minute is inappropriate because it can create excessive pressure, leading to discomfort, aspiration, or injury to the gastrointestinal tract. Gravity feeding or using an appropriate pump at a controlled rate is safer.
Choice C rationale
Holding the infant with head and shoulders slightly elevated during feeding is recommended. This position helps to prevent aspiration by ensuring that the formula flows smoothly through the esophagus and into the stomach, reducing the risk of regurgitation.
Choice D rationale
Microwaving refrigerated formula to room temperature is unsafe because microwaving can create hot spots in the formula, posing a burn risk to the infant. It is safer to warm the formula by placing the bottle in warm water and ensuring an even temperature.
Correct Answer is D
Explanation
Choice A rationale
An older client one day postoperative with a colostomy for colon cancer may have complex needs that require the expertise of an RN rather than a PN.
Choice B rationale
An older adult scheduled for foot amputation due to diabetes complications may also have complex needs and potential complications that necessitate the supervision of an RN.
Choice C rationale
An adult with alcoholism, cirrhosis, and hepatic encephalopathy is likely to have complex medical issues and require close monitoring and interventions, best suited for an RN.
Choice D rationale
An adult one day postoperative for a laparoscopic cholecystectomy is generally stable and has less complex needs, making them an appropriate assignment for a PN.
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