the nurse is assessing a client who reports severe pain in the right lower quadrant of the abdomen which sign would most likely indicate appendicitis the nurse is assessing a client who reports severe pain in the right lower quadrant of the abdomen which sign would most likely indicate appendicitis
Logo

Nursing Elites

ATI LPN

ATI Medical Surgical Proctored Exam 2019 Quizlet

1. When assessing a client reporting severe pain in the right lower quadrant of the abdomen, which sign would most likely indicate appendicitis?

Correct answer: A

Rationale: Rebound tenderness at McBurney's point is a classic sign of appendicitis. This sign indicates peritoneal irritation, a common feature of appendicitis. McBurney's point is located in the right lower quadrant of the abdomen and is a focal point for assessing tenderness. Positive Murphy's sign is associated with cholecystitis, not appendicitis. Rovsing's sign is elicited by palpation of the left lower quadrant resulting in pain in the right lower quadrant, also suggestive of appendicitis. Cullen's sign is associated with acute pancreatitis and manifests as periumbilical ecchymosis.

2. A client is reinforcing teaching with a nurse about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because inhaling deeply and slowly elevates the cylinder on the spirometer, promoting lung expansion. Choice A is incorrect as exhaling deeply before inhaling is not the correct technique for using an incentive spirometer. Choice C is incorrect as inhaling quickly through the spirometer does not promote optimal lung expansion. Choice D is incorrect as inhaling several short breaths does not facilitate the proper use of an incentive spirometer.

3. A client has a new prescription for enalapril. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: Monitor for a dry cough. When a client is prescribed enalapril, it is important to monitor for a dry cough because it can be a side effect that indicates a potential issue like angioedema. This side effect needs close attention as it may require discontinuation of the medication to prevent further complications. Choices B, C, and D are incorrect because enalapril does not need to be taken at bedtime, does not interact with grapefruit juice, and can be taken without regard to meals.

4. While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?

Correct answer: D

Rationale: Cracks at the corners of the mouth, known as angular cheilitis, can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). The nurse should ensure that the client receives adequate B vitamins through foods rich in these nutrients or supplements to address the deficiency, which can help improve the condition of the client's mouth.

5. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.

Similar Questions

What are the nursing interventions for a patient with neutropenia?
What is the primary function of protein in the body?
A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?
A client with liver cirrhosis and ascites is being treated with spironolactone. What is a key nursing consideration for this medication?
What is the interval between tetanus toxoid doses for pregnant women?

Access More Features

ATI Basic

  • 50,000 Questions with answers
  • All ATI courses Coverage
    • 30 days access @ $69.99

ATI Basic

  • 50,000 Questions with answers
  • All ATI courses Coverage
    • 90 days access @ $149.99