The nurse is assessing a client with suspected appendicitis. Which finding is most indicative of this condition?

Rebound tenderness in the right lower quadrant

Diffuse abdominal pain

Decreased bowel sounds

Elevated blood pressure

Answer and Explanation

The Correct Answer is A

Choice A reason: Rebound tenderness in the right lower quadrant (McBurney’s point) is a hallmark of appendicitis, indicating peritoneal irritation from an inflamed appendix. This localized pain, elicited on palpation release, is highly specific, guiding urgent surgical evaluation to prevent rupture and peritonitis.

Choice B reason: Diffuse abdominal pain is nonspecific and occurs in various conditions, not uniquely appendicitis, which typically presents with localized right lower quadrant pain. Rebound tenderness is more diagnostic, as it directly reflects appendiceal inflammation, making it the priority finding.

Choice C reason: Decreased bowel sounds may occur in appendicitis due to ileus but are nonspecific, seen in other abdominal conditions. Rebound tenderness is more indicative, as it localizes to the appendix, confirming peritoneal irritation, critical for diagnosing acute appendicitis.

Choice D reason: Elevated blood pressure is not specific to appendicitis and may reflect pain or stress. Rebound tenderness directly indicates appendiceal inflammation, making it the most reliable finding, as it guides diagnosis and urgent intervention to prevent complications like perforation.

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Correct Answer is C

Explanation

Choice A reason: Teaching mask use, hand washing, and distancing is important for preventing COVID-19 spread but is secondary to immediate isolation. Suspected cases require prompt separation to minimize transmission risk, as symptoms like fever and anosmia suggest high infectivity, making isolation the priority action.

Choice B reason: Counseling family to monitor symptoms is a follow-up measure, not the immediate priority. Isolation prevents active transmission in the emergency department, where the client is currently located. Family monitoring is relevant post-discharge but secondary to containing the virus in the acute setting.

Choice C reason: Isolation is the most critical action for a suspected COVID-19 case, as symptoms like fever, anosmia, and aches indicate potential infectivity. Separating the client from others without proper PPE prevents airborne and droplet transmission, protecting patients and staff in the emergency department, making it the priority.

Choice D reason: Reporting COVID-19 results to health authorities is mandatory but occurs after test confirmation. Immediate isolation prevents transmission in the emergency department while awaiting results. Reporting is a secondary administrative action, as the priority is containing the virus in the acute care setting.

A. Encourage early ambulation B. Apply warm compresses to the leg C. Restrict fluid intake D. Elevate the affected leg

Correct Answer is D

Explanation

Choice A reason: Early ambulation prevents stasis but is contraindicated in acute deep vein thrombosis, as it risks dislodging the clot, causing pulmonary embolism. Leg elevation reduces swelling and promotes venous return, making it the priority intervention to manage acute DVT safely.

Choice B reason: Warm compresses may increase blood flow but are not standard for deep vein thrombosis, as they risk clot dislodgement. Leg elevation reduces edema and venous pressure, improving circulation without mobilizing the clot, making it the preferred intervention for DVT management.

Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents blood viscosity increases that exacerbate deep vein thrombosis. Leg elevation directly reduces swelling and promotes venous return, addressing the primary issue of venous stasis, making it the priority over fluid restriction.

Choice D reason: Elevating the affected leg reduces edema and venous pressure in deep vein thrombosis by promoting venous return to the heart. This decreases clot propagation risk and alleviates pain, making it a key intervention to manage acute DVT effectively and prevent complications.

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The nurse is assessing a client with suspected appendicitis. Which finding is most indicative of this condition?

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Naxlex Comprehensive Predictor Exams

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