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Appendicitis NCLEX (1).
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Appendicitis NCLEXAnswer 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. - ANS-"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."
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. - ANS-"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: 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." - ANS-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
"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." - ANS-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
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." - ANS-"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 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. - ANS-"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 4
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