# A 15-year-old female client is evaluated for right lower quadrant pain that started 18 hours ago. The provider is considering acute appendicitis and ovarian torsion. The nurse's assessment findings are listed below. Which findings more strongly support acute appendicitis than ovarian torsion? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617274&lang=en  
> language: en  
> subject: Alterations in Body Systems  
> category: PA

## Question

A 15-year-old female client is evaluated for right lower quadrant pain that started 18 hours ago. The provider is considering acute appendicitis and ovarian torsion. The nurse's assessment findings are listed below. Which findings more strongly support acute appendicitis than ovarian torsion? Select all that apply.

1Urine pregnancy test (hCG) collected this morning is negative
2Tenderness to light and deep palpation of the right lower quadrant
3Two episodes of nonbloody vomiting since the pain first began
4Pain began periumbilically and moved to the right lower quadrant
5Right lower quadrant pain when the left lower quadrant is pressed
6Loss of appetite began before the first episode of vomiting
7Last menstrual period started 13 days ago and was of normal flow
8Right lower quadrant pain when the right hip is passively extended

## Explanation

Migration of pain from the periumbilical area to the right lower quadrant, anorexia that precedes vomiting, a positive Rovsing sign, and a positive psoas sign reflect visceral-then-parietal inflammation of the appendix and favor appendicitis. Right lower quadrant tenderness and vomiting occur in both conditions, a negative hCG only excludes pregnancy-related causes, and a mid-cycle menstrual timing points, if anything, toward an ovarian cause.

## In-depth explanation

Quick answer
Periumbilical-to-RLQ migration, anorexia before vomiting, Rovsing sign, and psoas sign (options 4, 6, 5, 8).

Why this is correct
The question asks which findings discriminate, not which findings are present in appendicitis. Early appendiceal inflammation is felt vaguely at the umbilicus and then localizes when the parietal peritoneum is irritated, and anorexia typically comes before vomiting. Rovsing and psoas signs show peritoneal or retroperitoneal irritation from the inflamed appendix. Ovarian torsion usually starts suddenly in the lower quadrant with early, prominent vomiting.

Easy analogy or mental picture
Appendicitis is like a rumor that starts vaguely in the middle of town and then settles on one address; torsion is a sudden alarm going off right at the house.

Memory hook
Middle then right, hungry-less before sick, plus Rovsing and psoas = appendix.

NCLEX decision rule
When comparing two diagnoses, choose findings that separate them; findings shared by both do not support one over the other.

Why the other choices are wrong
RLQ tenderness (option 2) and vomiting (option 3) are tempting because they are part of every appendicitis description, but torsion also causes lower quadrant tenderness and vomiting, often earlier and more prominently, so they do not discriminate. A negative hCG (option 1) is tempting because ruling out pregnancy feels like narrowing toward appendicitis, but it excludes ectopic pregnancy only and does not separate appendix from ovary. A menstrual period 13 days ago (option 7) places the client at mid-cycle, which raises ovarian considerations such as a ruptured follicle or cyst rather than supporting appendicitis.

References
1StatPearls: AppendicitisPain migration, anorexia, Rovsing and psoas signs, and differential diagnosis in adolescent females

## Clinical scenario

Scenario
An adolescent female with 18 hours of right lower quadrant pain is being evaluated for appendicitis versus ovarian torsion.

## Key concepts

- **Rovsing sign** — Right lower quadrant pain produced by pressing the left lower quadrant, suggesting peritoneal irritation from appendicitis.
- **Psoas sign** — Right lower quadrant pain on passive extension of the right hip, suggesting an inflamed appendix lying against the psoas muscle.
- **Ovarian torsion** — Twisting of the ovary on its supporting ligaments, causing sudden severe lower abdominal pain with nausea and vomiting.

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