Appendicitis NCLEX Exam 2022

Appendicitis NCLEX Exam 2022

The nurse would increase the comfort of the patient with appendicitis by:

"a. Having the patient lie prone

• Flexing the patient's right knee
• Sitting the patient upright in a chair
• Turning the patient onto his or her left side

(- Correct answer: B"

The patient with appendicitis usually prefers to lie still, often with the right leg flexed to decrease pain.

"The nurse is caring for a patient in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the patient complains of pain in the right lower quadrant. The nurse will document this as which of the following diagnostic signs of appendicitis?"a. Rovsing sign

• referred pain
• Chvostek's sign
• rebound tenderness

(- Correct Answer A In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant.

Which of the following position should the client with appendicitis assume to relieve pain ?

• Prone
• Sitting
• Supine
• Lying with legs drawn up

(- Correct Answer: D Lying still with legs drawn up towards chest helps relive

tension on the abdominal muscle, which helps to reduce the amount of discomfort felt. Lying flat or sitting may increase the amount of pain experienced

"When evaluating a male client for complications of acute pancreatitis, the nurse

would observe for:

"a. increased intracranial pressure.

• decreased urine output.
• bradycardia.
• hypertension."

(- Correct Answer: B

Rationale: Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn't related to acute pancreatitis."

"When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

"a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture.

• Obstruction of the appendix reduces arterial flow, leading to ischemia,

inflammation, and rupture of the appendix.

• The appendix may develop gangrene and rupture, especially in a middle-aged

client.

• Infection of the appendix diminishes necrotic arterial blood flow and increases

venous drainage." (- Answer B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion.Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

"A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?

a) Left lower quadrant

b) Left upper quadrant

c) Right upper quadrant

d) Right lower quadrant

(- Correct answer: d) Right lower quadrant"

Rationale: The pain of acute appendicitis localizes in the right lower quadrant

(RLQ) at McBurney's point, an area midway between the umbilicus and the right

iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.

The nurse is monitoring a client diagnosed with appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begns to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the appropriate nursing intervention?"1. Notify the Physician

• Administer the prescribed pain medication
• Call and ask the operating room team to perform the surgery as soon as possible
• Reposition the client and apply a heating pad on warm setting to the client's

abdomen

(- correct answers:- 1"

"1. Based on the assessment information the nurse should suspect peritonitis, a complication that is associated with appendicitis, and notify the physician.

• Administering pain medication is not an appropriate intervention
• Scheduling surgical time is not within the scope of practice of an RN.
• Heat should never be applied to the abdomen of a patient suspected of having

peritonitis because of the risk of rupture."

A client is admitted with right lower quadrant pain, anorexia, nausea, low-grade fever, and elevated white blood cell count. Which complication is most likely the cause? 1. A. fecalith

• Bowel Kinking
• Internal blowel occlusion
• Abdominal wall swelling

(- "Answer 1