Nokea
The nurse is caring for a client with appendicitis. Which of the following statements are correct regarding this condition? Select all that apply.
- A. McBurney's point tenderness is a sign of appendicitis
- B. Appendicitis is more common among males
- C. A low carbohydrate diet is a risk factor for appendicitis
- D. Diagnosis of appendicitis is confirmed by endoscopic retrograde cholangiopancreatography
- E. The client may have an elevated white blood cell count (WBC)
Correct Answer: A,E
Rationale: McBurney's point tenderness (A) and elevated WBC (E) are hallmark signs of appendicitis. It is not more common in males (B), low-carb diets (C) are not a risk factor, and ERCP (D) is not used for diagnosis.
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The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Notes
0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia.
Laboratory Results
white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3]
hemoglobin: 13.9 g/dL [14–18 g/dL]
hematocrit: 41.7% [42%–52%]
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Insert a peripheral venous access device (VAD), obtain a stool specimen for culture and sensitivity (C & S), prepare the client for surgery, request an order for a clear liquid diet.
- B. Peritonitis, diverticulitis, appendicitis, gastroenteritis.
- C. Lung sounds, pulse, temperature, hemoglobin and hematocrit.
Correct Answer: B: Appendicitis; A: Insert a peripheral VAD, prepare the client for surgery; C: Temperature, pulse
Rationale: The clinical presentation (right lower quadrant pain, fever, leukocytosis, rigid abdomen) strongly suggests appendicitis (B). Inserting a VAD and preparing for surgery (A) are critical for anticipated appendectomy. Monitoring temperature and pulse (C) tracks infection and hemodynamic status.
The nurse is caring for a client who is newly prescribed cimetidine. The nurse understands that this medication is prescribed to treat which condition?
- A. Cystic fibrosis
- B. Clostridium difficile
- C. H. pylori infection
- D. Crohn’s disease
Correct Answer: C
Rationale: Cimetidine, an H2 receptor blocker, is used in H. pylori infection to reduce gastric acid, aiding in ulcer healing alongside antibiotics. It is not indicated for cystic fibrosis, C. difficile, or Crohn’s disease.
Your client has just undergone a fecal diversion surgery and will be discharged to their home. Which type of social support person or support network is most likely to benefit this client in terms of post-discharge self-care and physical adaptations necessary for this client?
- A. A peer support network like an ostomy group in the community to promote self-care
- B. An emotional support person to help the client cope with the altered bodily image
- C. An instrumental support network to help with activities of daily living (ADLs)
- D. A church group of volunteers who can transport the client to health care provider (HCP) appointments
Correct Answer: A
Rationale: A peer support network like an ostomy group (A) provides practical self-care education and emotional support, critical for adapting to a new colostomy.
A nurse is caring for a 57 year old client and is teaching them about screening for colorectal cancer. Which of the following information should the nurse include?
- A. It is recommended that colon cancer screening with a colonoscopy should begin at age 45.
- B. It is recommended that colon cancer screening with a colonoscopy should begin at age 70.
- C. It is recommended that colon cancer screening with a colonoscopy should begin at age 40.
- D. It is recommended that colon cancer screening with a colonoscopy should begin at age 65.
Correct Answer: A
Rationale: Current guidelines recommend colonoscopy screening for colorectal cancer starting at age 45 (A) for average-risk individuals.
A client with peptic ulcer disease from chronic nonsteroidal anti-inflammatory drug (NSAID) use is prescribed misoprostol. The nurse would be correct in informing the client that this medication does which of the following?
- A. Decreases gas formation
- B. Increases the speed of gastric emptying
- C. Lines the stomach for protection
- D. Increases the lower esophageal sphincter pressure
Correct Answer: C
Rationale: Misoprostol (C) protects the stomach by increasing mucus production and reducing acid secretion, helping to heal NSAID-induced ulcers.