Ch. 58 Appendicitis (Davis Advantage)

Which observation would indicate that the client's appendix had perforated? Changes in blood pressure and pulse Temperature 99.2°F 1+ pitting edema bilaterally lower legs Client experiences excessive thirst

Changes in blood pressure and pulse

The nurse is caring for a client with suspected appendicitis who has just arrived at the nursing unit. The nurse knows which test is most commonly used to diagnose appendicitis? Magnetic resonance imaging Computed tomography scan X-ray Ultrasound

Computed tomography scan

Which potential complications can arise if appendicitis is not diagnosed and treated promptly? Select all that apply. Development of abscess Viral infection Deep vein thrombosis Peritonitis Gangrene

Development of abscess Peritonitis Gangrene

Andrew is frightened to have surgery. He asks the nurse why surgery is needed, saying, "What's the worst thing that could happen if I just leave it alone?" What complications should the nurse include in the teaching discussion? Select all that apply. It will heal over time. Gangrene can occur and is life-threatening. Abscess can happen if the bacterial invasion is slow. The pain becomes excruciating. Rupture can occur in as little as 24 hours, which results in peritonitis.

Gangrene can occur and is life-threatening. Abscess can happen if the bacterial invasion is slow. Rupture can occur in as little as 24 hours, which results in peritonitis.

A client has been diagnosed with acute appendicitis and is being prepped for surgery. Which provider's order should the nurse question? Initiate intravenous access. Maintain NPO status. Administer an enema. Withhold pain medication until the surgical consent is signed.

Initiate intravenous access.

In managing postoperative care for a client who had an appendectomy, which nursing action would be included? Positioning the client on the right side for comfort Maintaining complete bed rest for the first 24 hours postoperatively Monitoring for return of bowel sounds before advancing diet Medicating the client for pain relief around the clock

Monitoring for return of bowel sounds before advancing diet

Andrew's appendectomy is performed, revealing that the appendix has ruptured. Based on this finding, what should the nurse include in the postoperative care? Providing nourishment by administering total parenteral nutrition (TPN) in the postoperative period Advancing diet as tolerated within 24 hours of surgery Monitoring nasogastric (NG) tube attached to low intermittent suction for drainage Maintaining complete bedrest with both side rails up to ensure safety Check Answer

Monitoring nasogastric (NG) tube attached to low intermittent suction for drainage

Which order would the nurse question in a client who is admitted for appendicitis? Having the client sign the consent form for an appendectomy Maintaining NPO status prior to surgery Obtaining medical consult for therapeutic management of inflammation Monitoring vital signs

Obtaining medical consult for therapeutic management of inflammation

The nurse is taking care of a client diagnosed with acute appendicitis who is awaiting surgical intervention. The client has been medicated for pain as ordered. What additional comfort measure should the nurse include in the plan of care to relieve the client's pain? Place a warm compress on the area that the client identifies as the source of pain. Position for comfort on the right side with pillow support. Maintain patient's position in high Fowler's to decrease pressure on the diaphragm. Place an ice pack to the right lower quadrant.

Place an ice pack to the right lower quadrant.

Andrew, a 20-year-old male college student, presents at the emergency room with recent onset acute abdominal pain in the right lower quadrant along with nausea, but no vomiting. He denies history of any comorbid conditions and does not take any prescription or over-the-counter medications. He is physically active and in overall good health apart from the symptoms he's experiencing. After the healthcare provider makes a clinical diagnosis of appendicitis, the nurse begins to prepare him for surgery. Andrew is experiencing pain of 4 on a 1 to 10 scale prior to the surgery. Which interventions should be used to alleviate pain? Select all that apply: Apply warm compress to the right lower quadrant Position the client with the knees flexed Apply ice pack to the right lower quadrant Administer opioid analgesic prior to having the client sign the surgical consent Maintain NPO status prior to surgery

Position the client with the knees flexed Apply ice pack to the right lower quadrant

Which findings would be consistent with a clinical diagnosis of acute appendicitis? Select all that apply. Elevated white blood cell count with a shift to the right Hypothermia Presentation of pain in the left lower quadrant correlated with McBurney's point Presence of Rovsing's sign eliciting referred pain in the right lower quadrant Nausea and vomiting

Presence of Rovsing's sign eliciting referred pain in the right lower quadrant Nausea and vomiting

Andrew continues to recover from surgery and hopes that the NG tube will be removed soon. What clinical finding supports the removal of the NG tube? Client has resumed ambulation with minimal assistance. Less pain medication has been administered during a 12-hour shift. Client is able to tolerate small sips of liquids without nausea or vomiting. Presence of bowel sounds.

Presence of bowel sounds.

Andrew verbally consents to surgery. Which statement about the consent is true? Andrew's parents must be contacted since he is younger than 21. The consent must be signed before narcotics are administered. A verbal consent is acceptable and the nurse can document that. The consent cannot be signed until the anesthesiologist sees Andrew.

The consent must be signed before narcotics are administered.

A nurse is preparing to perform Rovsing's sign to determine if the client has appendicitis. Which action is incorrect? The nurse performs hand hygiene prior to the assessment. The nurse places his or her hands on the right side of the abdomen. The nurse provides an explanation of his or her action prior to touching the client. The nurse asks the client if he or she has any questions prior to touching the client.

The nurse places his or her hands on the right side of the abdomen.

In hopes of promoting a prompt recovery, which of the following aspects will be included in care planning for this client? Select all that apply. Use of incentive spirometer Early ambulation as tolerated Discontinuation of antibiotic therapy upon client becoming afebrile Assistance with turning, coughing, and deep breathing techniques (TCDB) Limiting oral fluids Check Answer

Use of incentive spirometer Early ambulation as tolerated Assistance with turning, coughing, and deep breathing techniques (TCDB)

The nurse is performing discharge teaching with Andrew. Which statement by him requires additional teaching? "I will not drive after taking my pain medication." "If my wound opens up, I'll call the surgeon." "My antibiotics are used as needed." "I'll follow up with my surgeon in 7 days."

"My antibiotics are used as needed."

The nurse is assessing the client's incision. Since the appendix was ruptured, what would the nurse expect to see? A larger incision Retention sutures in place Steri-strips over a small puncture wound Incision covered by an occlusive dressing

A larger incision

Which assessment findings are consistent with identification of positive McBurney's point in a client with suspected appendicitis? Select all that apply. Abdominal tenderness Left lower quadrant pain Guarding in response to pain Right lower quadrant pain Hyperactive bowel sounds

Abdominal tenderness Guarding in response to pain Right lower quadrant pain