Medical Surgical Appendicitis #5

Question

Which assessment finding should the nurse report immediately while assessing a client reporting right lower abdominal pain?

Answers

  1. Round, soft abdomen
    • Rationale:

      This answer is not correct because a round, soft abdomen is a normal abdominal assessment. A perforated appendix would produce a hard, board-like abdomen and should be reported immediately.

  2. Bowel sounds present
    • Rationale:

      This answer is not correct because bowel sounds present are expected with a normal abdominal assessment. Bowel sounds may be hypoactive with appendicitis. If perforation of the appendix is diagnosed, bowel sounds may be absent.

  3. Cool, clammy skin
    • Rationale:

      This answer is correct because cool, clammy skin indicates shock associated with a perforation in the abdomen. This is life-threatening and should be reported immediately.

  4. Rebound hypertension
    • Rationale:

      This answer is not correct because hypotension will occur (not hypertension) if a client has experienced perforation and should be reported immediately. Other symptoms of perforation and shock include a hard, board-like abdomen, tachycardia, and cool, clammy skin.

Overview

Clinical manifestations of perforation of the appendix includes symptoms of shock, including cool, clammy skin, hypotension, tachycardia. Another obvious symptom of perforation is a board-like abdomen.

Explanation

Learning Outcomes

Appendicitis is inflammation of the appendix. It presents as pain in the lower right abdomen, nausea, vomiting, decreased appetite, fever, constipation/diarrhea and/or abdominal bloating. For diagnosis, a physical assessment of pain, blood test, and CT scan is used. Once confirmed by CT, an appendectomy is the next step. It is important to visually see the appendix before performing surgery. This will also confirm the appendix has not perforated or ruptured, requiring emergent surgery. An appendectomy is a surgical procedure to remove the appendix and will be performed soon after confirmation of appendicitis since there is a high risk of perforation or rupture in appendicitis. Clinical manifestations of perforation of the appendix includes symptoms of shock, including cool, clammy skin, hypotension, tachycardia. Another obvious symptom of perforation is a board-like abdomen.

Test Taking Tip

The nurse should know the signs of perforation when a client presents with right lower abdominal pain that indicates potential appendicitis.

Video Rationale