A nurse is assessing a client suspected of having acute cholecystitis. Which of the following techniques should the nurse use to elicit Boas' sign?
Percussion of the left lower quadrant
Deep palpation of the epigastric region
Palpation of the right upper quadrant during inspiration
Auscultation of the left upper quadrant
The Correct Answer is C
Choice A reason:
Percussion of the left lower quadrant is not relevant to assess for Boas' sign, which involves the right upper quadrant.
Choice B reason:
Deep palpation of the epigastric region is not associated with Boas' sign. Boas' sign involves palpation of the right subscapular area.
Choice C reason:
This statement is correct. Boas' sign is elicited by palpating the right upper quadrant during inspiration. The client may experience referred pain to the right subscapular area, indicating irritation of the phrenic nerve by the inflamed gallbladder.
Choice D reason:
Auscultation of the left upper quadrant is not relevant to assessing for Boas' sign, which involves the right upper quadrant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Avoiding NSAIDs is essential for clients with peptic ulcer disease as they can worsen the condition and increase the risk of bleeding.
Choice B reason:
Following a low-fat diet does not directly impact stomach acid production, but it can help prevent irritation to the stomach lining by reducing the intake of potentially irritating foods.
Choice C reason:
This statement is correct. Proton pump inhibitors (PPIs) are commonly prescribed to reduce stomach acid production and promote ulcer healing. It is crucial for the client to continue taking PPIs as directed by their healthcare provider.
Choice D reason:
This statement is incorrect and indicates a need for further teaching. Alcohol can irritate the stomach lining and exacerbate peptic ulcer disease. Clients with peptic ulcers should avoid or minimize alcohol consumption.
Correct Answer is A
Explanation
Choice A reason:
This statement is correct. H2 receptor blockers can sometimes cause an increase in serum potassium levels. The nurse should monitor the client's potassium levels closely to detect any abnormalities.
Choice B reason:
H2 receptor blockers do not typically affect blood glucose levels, so monitoring blood glucose is not the priority in this scenario.
Choice C reason:
H2 receptor blockers are not known to have a significant impact on serum creatinine levels, so monitoring creatinine is not the priority in this case.
Choice D reason:
H2 receptor blockers are not known to affect the CBC, so monitoring the complete blood count is not the priority for this client.
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