The client has a possible diagnosis of appendicitis. On physical examination, the nurse should assess for tenderness on palpation at McBurney's point, located at which pictured site?

Answer and Explanation

The Correct Answer is B

McBurney's point is located approximately one-third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus (navel), on the right side of the abdomen.

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Correct Answer is D

Explanation

D. Bloody diarrhea is a hallmark symptom of ulcerative colitis, particularly during disease flares. It typically presents as frequent and urgent bowel movements containing blood, mucus, and pus. Crohn's disease, on the other hand, may present with bloody diarrhea but usually involves less frequent bowel movements.
A. Both ulcerative colitis and Crohn's disease can manifest at various ages, including during adolescence and early adulthood.
B. Abdominal pain and cramping are common symptoms of both ulcerative colitis and Crohn's disease.
C. Weight loss can occur in both ulcerative colitis and Crohn's disease due to factors such as decreased appetite, malabsorption, and inflammation of the gastrointestinal tract.

A. giving the client a heating pad to place on the abdomen for comfort. B. getting the client up to walk at least once every hour. C. administering a cleansing enema in preparation for surgery. D. administering prophylactic IV antibiotics. E. keeping the client NPO.

Correct Answer is ["D","E"]

Explanation

D. Prophylactic antibiotics are often administered before surgery for appendicitis to reduce the risk of postoperative infection, particularly in cases of suspected or confirmed appendiceal perforation.
E. Keeping the client NPO (nothing by mouth) is a standard precaution before surgery to prevent aspiration of gastric contents during anesthesia induction and to reduce the risk of surgical complications.
A. Applying heat to the abdomen can potentially worsen inflammation and increase the risk of appendiceal rupture.
B. Ambulation may exacerbate the pain and increase the risk of complications, such as appendiceal rupture.
C. Administering a cleansing enema in preparation for surgery may be appropriate in some cases to help prepare the bowel for surgery, particularly if there is concern about bowel obstruction or to reduce the risk of contamination during surgery.

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The client has a possible diagnosis of appendicitis. On physical examination, the nurse should assess for tenderness on palpation at McBurney's point, located at which pictured site?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While obtaining a nursing history from a client with inflammatory bowel disease, the nurse recognizes that the client most likely has ulcerative colitis rather than Crohn's disease when the client reports experiencing:

Correct Answer is D

Explanation

The nurse is caring for a client who has suspected appendicitis. While waiting for surgery, nursing interventions for this client would include: (NOTE: Assume that there are physician's orders for all interventions which would require them.) (SELECT ALL THAT APPLY)

Correct Answer is ["D","E"]

Explanation

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The client has a possible diagnosis of appendicitis. On physical examination, the nurse should assess for tenderness on palpation at McBurney's point, located at which pictured site?