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 C
Explanation
Choice A Reason: Cushing's is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excess cortisol and aldosterone production.
Choice B Reason: Diabetes insipidus is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive water loss and dilution of blood.
Choice C Reason: Addison's is an expected health problem in a client with high potassium level, as it causes high potassium level due to insufficient cortisol and aldosterone production.
Choice D Reason: Diarrhea is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive fluid and electrolyte loss.
Correct Answer is D
Explanation
Choice A Reason: Ketoacidosis is not likely to be the complication that the nurse should suspect, as it is caused by high blood glucose levels and results in symptoms such as nausea, vomiting, abdominal pain, fruity breath, and deep breathing.
Choice B Reason: Hyperglycemia is not likely to be the complication that the nurse should suspect, as it is caused by high blood glucose levels and results in symptoms such as thirst, polyuria, blurred vision, dry skin, and fatigue.
Choice C Reason: Nephropathy is not likely to be the complication that the nurse should suspect, as it is a chronic kidney disease that develops over time due to diabetes and results in symptoms such as proteinuria, edema, hypertension, and anemia.
Choice D Reason: Hypoglycemia is likely to be the complication that the nurse should suspect, as it is caused by low blood glucose levels and results in symptoms such as sweating, tachycardia, lightheadedness, shakiness, hunger, and confusion.
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