Patho Patho #22

Question

Which nursing assessment takes priority in a client with acute appendicitis?

Answers

  1. Temperature of 38.9 C
    • Rationale:

      This answer choice is not correct because an elevated temperature is an expected finding in a client with acute appendicitis and is therefore not the priority assessment finding.

  2. Reports of nausea and vomiting
    • Rationale:

      This answer choice is not correct because nausea and vomiting are expected findings in a client with acute appendicitis and is therefore not the priority assessment finding.

  3. Reports pain of 7 on a scale of 1-10
    • Rationale:

      This answer choice is not correct because reports of pain are expected findings in a client with acute appendicitis and is therefore not the priority assessment finding.

  4. Rigid, board-like abdomen
    • Rationale:

      This answer is correct because a rigid, board-like abdomen is an indicator of peritonitis which is a very critical potential complication of acute appendicitis. If this is assessed, it must be reported to the provider immediately.

Overview

The focus of this question is asking the nurse to determine which assessment finding is most critical in a client with a diagnosis of acute appendicitis. A rigid, board-like abdomen is a classic manifestation of peritonitis and is therefore the most critical assessment finding. An elevated temperature, nausea and vomiting and pain are expected findings in a client with acute appendicitis.

Explanation

Learning Outcomes

Acute appendicitis occurs when the appendix becomes acutely inflamed usually due to infection. Peritonitis is a critical potential complication of acute appendicitis which could lead to sepsis, septic shock, and death. A rigid and board like abdomen is the most classic manifestation of peritonitis and must be reported to the provider immediately if assessed in a client with this diagnosis.

Test Taking Tip

When reviewing pathophysiology, make sure to learn, understand and master the clinical manifestations that indicate the worst possible potential complications of disease processes.

Video Rationale