Appendicitis

A client complains of severe pain in the right lower quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions? 1. Encourage the client to change positions frequently in bed 2. Massage the right lower quadrant fo the abdomen 3. Apply warmth to the abdomen with a heating pad 4. Use comfort measures and pillows to position the client

Correct answer: 4 Rationale: 1. Unnecesary movement will increase pain and should be avoided 2. If appendicitis is suspected, massage or palpation should never be performed as these actions may cause the appendix to rupture 3. If pain is caused by appendicitis, increased circulation from the heat may cause appendix to rupture 4. CORRECT: These are non-pharmacological methods of pain relief

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications? 1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis

Correct answer: 4 Rationale: Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.

A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? 1. Remove the dressing and leave the incision open to air. 2. Remove the drain if wound drainage is minimal. 3. Gently irrigate the drain to remove exudate. 4. Clean the area around the drain moving away from the drain.

Correct answer: 4. Rationale: The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

Which client requires immediate nursing intervention? The client who: a) complains of epigastric pain after eating. b) complains of anorexia and periumbilical pain. c) presents with ribbonlike stools. d) presents with a rigid, boardlike abdomen.

Correct answer: D Rationale: A rigid, board-like abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases significantly after 48 hours. A client with a large-bowel obstruction may have ribbonlike stools.

A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately? a) Hematocrit 42% b) Serum potassium 4.2 mEq/L c) Serum sodium 135 mEq/L d) White blood cell (WBC) count 22.8/mm3.

Correct answer: D Rationale: The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate appendicitis."

Bobby, a 13 year old is being seen in the emergency room for possible appendicitis. An important nursing action to perform when preparing Bobby for an appendectomy is to: a) administer saline enemas to cleanse the bowels b) apply heat to reduce pain c) measure abdominal girth d) continuously monitor pain

Correct answer: D Rationale: Pain is closely monitored in appendicitis. In most cases, pain medication is not given until prior to surgery or until the diagnosis is confirmed to be able to closely monitor the progression of the disease. A sudden change in the character of pain may indicate rupture or bowel perforation. Administering an enema or applying heat may cause perforation and abdominal girth may not change with appendicitis.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: 1. Provide access for wound irrigation. 2. Promote drainage of wound exudates. 3. Minimize development of scar tissue. 4. Decrease postoperative discomfort.

2. Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

A client presents with suspected appendicitis. The nurse should prepare the client for which collaborative​ intervention? A. Chest​ x-ray B. Abdominal ultrasound C. Electrolytes D. Complete blood count​ (CBC)

Answer: B Rationale: Abdominal ultrasound is the most effective test for diagnosing acute appendicitis. Electrolyte testing provides information relating to the mineral balance in the body. A CBC would be​ drawn, but it is not a definitive test to diagnose acute appendicitis. Chest​ x-rays are not used to diagnose abdominal conditions.

The nurse is evaluating a client recovering at home after an emergency appendectomy. Which observation indicates that​ self-care has been​ effective? (Select all that​ apply.) A. The client snacks on pretzels and club soda during the visit. B. The client plans to recover at home until cleared by the surgeon. C. The client uses a pillow to splint the incision before coughing. D. The client performs abdominal wound care appropriately. E. The client requests a prescription for more pain medication.

Answer: B, C, D ​Rationale: Observations that indicate that the client is appropriately providing​ self-care after an appendectomy include using a pillow to splint the incision before​ coughing, performing wound care​ appropriately, and planning to recover at home until cleared by the surgeon. Observations that indicate that​ self-care could improve include the need for more pain medication and ingesting a​ less-than-nutritious snack.

A teenage boy presents with suspected appendicitis. The caregiver​ asks, "Why did my son get​ this?" Which response by the nurse is the most​ appropriate? A. "Your son has been eating too much​ fiber." B. "Your son is eating too many fruits and​ vegetables." C. "Your son has not been getting enough​ exercise." D. "Your adolescent son is in a risk​ group."

Answer: D ​Rationale: Adolescent boys are at greatest risk for appendicitis. Appendicitis cannot be​ prevented, but certain dietary habits may reduce the risk of developing this condition. Eating foods that contain high fiber​ content, such as fresh fruits and​ vegetables, decreases the incidence of appendicitis.

A client with acute appendicitis asks the​ nurse, "Why​ don't you give me a heating​ pad? I think that will help me with my​ pain." The​ nurse's response should be based on which​ reason? A. It increases the need for fluids. B. It increases the spread of infection. C. It reduces white blood cell count. D. It encourages perforation.

Answer: D ​Rationale: Heat should not be applied to the abdomen since this increases circulation to the appendix and could cause perforation. It is not true that heat is avoided in acute appendicitis because it increases the need for​ fluids, increases the spread of​ infection, or reduces white blood cell count.

Which condition prompts the nurse to recommend a clear liquid diet to a post appendectomy​ client? A. Client denies any nausea B. Client no longer reports pain C. Client is afebrile D. ​Client's bowel sounds have returned

Answer: D ​Rationale: Once bowel sounds​ return, a client can begin taking clear fluids. The postoperative client is expected to be afebrile. Pain will subside as healing continues. Nausea would be subsided for the client to resume a PO​ diet, but it is the presence of bowel sounds that would indicate the gastrointestinal​ tract's ability to handle digestion.

A client has surgery for a perforated appendix with localized peritonis. In which position should the nurse place the client? A) Sims position B) Trendelenburg C) Semi-fowlers D) Dorsal recumbant

C. Semi-fowlers aids in drainage and prevents spread of infection throughout the abodominal cavity.

Which of the following would confirm a diagnosis of appendicitis? A. The pain is localized at a position halfway between the umbilicus and the right iliac crest. B. The patient describes the pain as occurring 2 hours after eating C. The pain subsides after eating D. The pain is in the left lower quadrant

Correct A Rationale: Pain over McBurney's point, the point halfway between the umbilicus and the iliac crest, is diagnostic for appendicitis.

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 2. Administer the prescribed pain medication 3. Call and ask the operating room team to perform the surgery as soon as possible 4. Reposition the client and apply a heating pad on warm setting to the client's abdomen

Correct answer: 1 Rationale: 1. Based on the assessment information the nurse should suspect peritonitis, a complication that is associated with appendicitis, and notify the physician. 2. Administering pain medication is not an appropriate intervention 3. Scheduling surgical time is not within the scope of practice of an RN. 4. Heat should never be applied to the abdomen of a patient suspected of having peritonitis because of the risk of rupture."

Postoperative nursing care for a client after an appendectomy should include which of the following? 1. Administering sitz baths four times a day. 2. Noting the first bowel movement after surgery. 3. Limiting the client's activity to bathroom privileges. 4. Measuring abdominal girth every 2 hours.

Correct answer: 2. Rationale: Noting the client's first bowel movement after surgery is important because this indicates that normal peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy. Ambulation is started the day of surgery and is not confined to bathroom privileges. The abdomen should be auscultated for bowel sounds and palpated for softness, but there is no need to measure the girth every 2 hours.

Which condition may occur if the client does not seek medication attention for acute appendicitis within 24 - 36 ​hours? (Select all that​ apply.) A. Seizure B. Constipation C. Nausea D. Peritonitis E. Perforation

Correct answer: D, E ​Rationale: If treatment is not​ initiated, tissue necrosis and gangrene result within 24-36 ​hours, leading to perforation​ (rupture). Perforation allows the contents of the gastrointestinal​ (GI) tract to flow into the peritoneal space of the​ abdomen, resulting in peritonitis. Appendicitis does not cause​ seizures, nausea, or constipation.

"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.