A nurse is assisting with data collection of a client with suspected cholecystitis. Which finding does the nurse expect to note if cholecystitis is present?
Murphy sign
McBurney sign
Cullen's sign
Homan sign
The Correct Answer is A
Choice A Reason: Murphy sign is a finding that indicates cholecystitis, which is inflammation of the gallbladder. It is elicited by palpating the right upper quadrant of the abdomen and asking the client to take a deep breath. The client will experience pain and stop breathing in if cholecystitis is present.
Choice B Reason: McBurney sign is a finding that indicates appendicitis, which is inflammation of the appendix. It is elicited by palpating the right lower quadrant of the abdomen at a point one-third of the distance from the anterior superior iliac spine to the umbilicus. The client will experience pain and tenderness if appendicitis is present.
Choice C Reason: Cullen's sign is a finding that indicates intra-abdominal bleeding, which can be caused by various conditions such as ruptured ectopic pregnancy, pancreatitis, or trauma. It is characterized by bruising around the umbilicus due to blood accumulation under the skin.
Choice D Reason: Homan sign is a finding that indicates deep vein thrombosis (DVT), which is a blood clot in a deep vein, usually in the leg. It is elicited by dorsiflexing the foot and squeezing the calf muscle. The client will experience pain and resistance if DVT is present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: The procedure will not be cancelled if the urinalysis indicates the presence of red blood cells, but it may indicate a urinary tract infection or kidney damage that needs further evaluation.
Choice B Reason: After the procedure, you will be encouraged to drink plenty of fluids, as this helps to flush out the contrast dye that was injected into your vein and prevent dehydration and kidney damage.
Choice C Reason: High frequency sound waves will not be used to identify renal system structures, but this is the principle of ultrasound imaging, which is a different diagnostic test.
Choice D Reason: You will not need to remain flat in bed for 4 hours following this procedure, but you may need to rest for a short period of time and avoid strenuous activities for the rest of the day.
Correct Answer is C
Explanation
Choice A Reason: Sharing personal hygiene items like razors is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, which are blood-borne infections.
Choice B Reason: Unprotected sexual activity is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other sexually transmitted infections.
Choice C Reason: Eating uncooked foods is a common way of spreading hepatitis A, as the virus can contaminate food or water that has been exposed to fecal matter from an infected person.
Choice D Reason: Getting a tattoo is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other blood-borne infections, if the equipment is not properly sterilized.
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