Appendicitis NCLEX
A school-aged child has an emergency appendectomy. The nurse should report which of the following to the HCP if notes in the immediate postoperative period. 1. abdominal pain, 2. tugging at the incision line, 3. thirst, 4 a rigid abdomen
Answer: 4 Rationale: A tense, rigid abdomen is an early symptom of peritonitis. The other findings are expected in the immediate postoperative period.
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 2. Bowel Kinking 3. Internal blowel occlusion 4. Abdominal wall swelling
"Answer 1 Rational: The client is experiencing appendicitis. A. fecalith is a fecal calculus, or stone, that occludes the lumen of the appendix and is the most common cause of appendicitis. Bowel wall swelling, kinking of the appendix, and external occlusion not internal occlusion, of the bowel by adhesions can also be cause of appendicitis."
Which of the following would indicate that Bobby's appendix has ruptured? " a) diaphoresis b) anorexia c) pain at Mc Burney's point d) relief from pain
Correct D all are normal signs of having appendicits and once you have relief from pain means you could have a rupture.
"A client has an appendectomy and develops peritonitis. The nurse should asses the client for an elevated temperature and which additional clinical indication commonly associated with peritonitis? "1. hyperactivity 2. extreme hunger 3. urinary retention 4. local muscular rigidity
Correct: 4 muscular rigidity over the affected area is a classic sign of peritonitis
"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. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. 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 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.
Answer: D "D) White blood cell (WBC) count 22.8/mm3 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."
an 18 yr old is admitted with an acute onset of right lower quadrant pain. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis A) urinary retention B) gastric hyperacidity C) rebound tenderness D) increased lower bowel motility
C) rebound tenderness is a classic subjective sign of appendicitis
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. Mr. Liu 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 "Pain over McBurney's point, the point halfway between the umbilicus and the iliac crest, is diagnosis for appendicitis. Options b and c are common with ulcers; option d may suggest ulcerative"
"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.
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
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 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.
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" "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."
which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective? 1. "i will take my temp each week and report any elevation." 2. "i will not need any pain meds when i go home." 3. i will take all of my antibiotics until they are gone." 4. i will not take a shower until my three month check up.
Correct 3 1. the client should check the temp twice a day. 2. it is not realistic to expect the client to experience no pain after surgery. 3 (CORRECT): this statement about taking all the antibiotics ordered indicates the teaching is effective. 4. clients may shower after surgery, but not taking a tub bath for three months after surgery is too long a time.
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 4 "1. ""Encourage the client..."" - unnecesary movement will increase pain and should be avoided 2. ""Massage the lower..."" - if appendicitis is suspected, massorge or palpation should never be performed as thes actions may cause the appendix to rupture 3. ""Apply warmth..."" - if pain is casused by appendicitis, increased circulation from the heat may cause appendix to rupture 4. ""Use comfort measures..."" - CORRECT: 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 4 "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 making a home health visit and finds the client experiencing right lower quadrant abdominal pain, which has decreased in intensity over the last day. The client also has a rigid abdomen and a temperature of 103.6 F. The nurse should intervene by: a) administer Tylenol (acetaminophen) for the elevated temperature b) advising the client to increase oral fluids c) asking the client when she last had a bowel movement d) notifying the physician
Correct D D. The client symptoms indicate appendicitis which requires immediate attention
"During the assessment of a patient with acute abdominal pain, the nurse should: a. perform deep palpation before auscultation b. obtain blood pressure and pulse rate to determine hypervolemic changes c. auscultate bowel sounds because hyperactive bowel sounds suggest paralytic ileus d. measure body temperature because an elevated temperature may indicate an inflammatory or infectious process.
Correct D Rationale: for the patient complaining of acute abdominal pain, nurse should take vital signs immediately. Increased pulse and decreasing blood pressure are indicative of hypovolemia. An elevated temperature suggests an inflammatory infectious process. Intake and output measurements provide essential information about the adequate of vascular volume. Inspect abdomen first and then auscultate bowel sounds. Palpation is performed next and should be gentle.
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: D A rigid, boardlike 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.
The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is essential to ask? A."When did you last eat?" B."Have you had surgery before?" C."Have you ever had this type of pain before?" D."What do you usually take to relieve your pain?"
answer A. When a person is admitted with possible appendicitis, the nurse should anticipate surgery. It will be important to know when she last ate when considering the type of anesthesia so that the chance of aspiration can be minimized. The other inoformation is "nice to know", but not essential.
Which of the nursing interventions should be implemented to manage appendicitis? a. Assess pain b. encourage oral intake of clear fluids. c. provide discharge teaching D. assess for symptoms of peritonitis.
answer D. Monitor for peritonitis because if the appendix ruptures, bacteria can enter the peritoneum. Pain will be managed with analgesics, and pt should be NPO for surgery. Discharge is not done at this time
