護理師評估一位疑似急性闌尾炎的病人。應預期發現什麼？
A nurse is assessing a client for signs of acute appendicitis. Which findings are expected?
- ARebound tenderness at McBurney's point✓ 正解麥氏點出現反彈痛
- BHyperactive bowel sounds腸鳴音亢進
- CPain relief with palpation觸診時疼痛緩解
- DLeft lower quadrant pain左下腹痛
急性闌尾炎（Acute Appendicitis）的典型臨床表現源於闌尾發炎與腹膜刺激。疼痛通常從上腹部或肚臍周圍轉移至右下腹（McBurney's point）。反彈痛（Rebound tenderness）是腹膜受到刺激的經典體徵，即放開壓迫處時引起的劇烈疼痛。評估時，應注意病人是否有發燒、噁心、嘔吐及白血球升高。診斷時需排除其他腹部急症，如憩室炎（通常在左下腹）或卵巢扭轉等。
Acute appendicitis arises from inflammation of the appendix and peritoneal irritation. Pain typically begins in the epigastric or periumbilical area and then migrates to the right lower quadrant (RLQ), specifically to McBurney's point. Rebound tenderness—severe pain upon release of pressure—is a classic sign of peritoneal irritation. The nurse should also assess for fever, nausea, vomiting, and an elevated white blood cell count. Differential diagnosis includes other acute abdominal conditions such as diverticulitis (typically in the LLQ) or ovarian torsion.