A nurse is caring for a client with acute pyelonephritis. Which area should the nurse percuss to assess for pain related to pyelonephritis?

McBurney's point on the abdomen

Psoas sign at the knee

Rovsing's Sign on the abdomen

costovertebral angle (CVA) on the back

Answer and Explanation

The Correct Answer is D

A. McBurney's point on the abdomen: McBurney's point is a location in the right lower quadrant of the abdomen that is significant in the assessment for appendicitis. It is not relevant to the assessment of pyelonephritis, which is a kidney infection.

B. Psoas sign at the knee: The psoas sign is a test for appendicitis, not pyelonephritis. It involves the patient lying on their back and lifting their right leg against resistance. If this movement causes pain in the lower right abdomen, it could indicate irritation of the psoas muscle due to an inflamed appendix.

C. Rovsing's Sign on the abdomen: Rovsing's sign is also a test for appendicitis. It involves palpating the left lower quadrant of the abdomen and observing if it causes pain in the right lower quadrant. The presence of pain in the right lower quadrant during palpation of the left lower quadrant can indicate appendicitis. This sign is not specific to pyelonephritis.

D. Costovertebral angle (CVA) on the back: The CVA is located on the back at the angle formed by the 12th rib and the spine. Percussion of the CVA is a common technique used to assess for kidney tenderness. In the case of acute pyelonephritis, infection and inflammation of the kidneys can cause tenderness and pain in the CVA area. Therefore, this area is assessed for pain related to kidney infections like pyelonephritis.

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Correct Answer is C

Explanation

A. Restrict calcium intake to one serving per day:
This statement is not accurate. Adequate calcium intake is essential for bone health. Calcium-rich foods are important for maintaining strong bones and are not directly related to gout or uric acid kidney stones. It's crucial to differentiate between dietary recommendations for different health conditions.

B. Take 3,000 mg of vitamin C daily:
High doses of vitamin C can increase urinary oxalate and uric acid levels, which might contribute to the formation of kidney stones. It is generally not recommended for individuals with a history of uric acid kidney stones.

C. The nurse should instruct the client to limit foods high in purines.
Dietary changes are important in managing gout and preventing uric acid kidney stones. Purines are natural substances found in many foods, especially animal products, and purine-rich foods can contribute to increased uric acid levels, leading to gout attacks and kidney stones.

D. Eat 12 oz of animal protein daily:
Consuming excessive amounts of animal protein, particularly red meat, can lead to higher purine intake, which is not advisable for individuals prone to gout and uric acid kidney stones. High animal protein intake can increase uric acid production and may exacerbate these conditions. Moderation in protein intake, especially from animal sources, is recommended.

A. Client with restricted activity B. Client who can ambulate C. Client with a cast D. Client with good nutrition E. Client with urinary and fecal incontinence

Correct Answer is ["A","C","E"]

Explanation

A. Client with restricted activity - Patients with limited mobility are at a higher risk for pressure ulcers because they are unable to change positions easily, leading to prolonged pressure on certain body parts.

B. Client who can ambulate - Patients who can ambulate have the ability to shift their body weight and change positions, reducing the risk of prolonged pressure on specific areas. Ambulation can improve circulation and reduce the risk of pressure ulcers

C. Client with a cast - Clients with casts are often limited in their ability to move or change positions, making them susceptible to pressure ulcers in areas where the cast creates pressure points on the skin.

D. Client with good nutrition - Proper nutrition is essential for overall health, including skin health. Adequate nutrition promotes wound healing and tissue repair. Good nutrition is not a risk factor for pressure ulcers; in fact, it can contribute to preventing them by maintaining healthy skin.
E. Client with urinary and fecal incontinence - Incontinence can lead to moisture on the skin, making it more susceptible to breakdown. Prolonged exposure to moisture, especially in the presence of urine or feces, can increase the risk of pressure ulcer development.

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A nurse is caring for a client with acute pyelonephritis. Which area should the nurse percuss to assess for pain related to pyelonephritis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing dietary teaching to a client who has a history of gout and recurring uric acid kidney stones. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

The nurse understands that certain patients are more susceptible to pressure ulcer development. Which clients should the nurse identify as being at an increased risk for this health problem? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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