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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Morse Scale:
The Morse Scale, also known as the Morse Fall Scale, is used to assess a patient's risk of falling. It evaluates various factors such as history of falling, secondary diagnosis, ambulatory aids, IV therapy, gait, and mental status. It is primarily focused on assessing the risk of falls, not pressure ulcers.
B. Braden Scale:
As previously mentioned, the Braden Scale assesses a patient's risk for developing pressure ulcers. It takes into account sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The scale helps healthcare providers determine the level of risk a patient has for developing pressure sores and guides interventions to prevent them.
C. Bristol Scale:
The Bristol Stool Scale is used to classify the form of human feces into seven categories. It is a medical aid designed to classify the form of human feces into seven categories. This scale is primarily used to assess bowel movements and is unrelated to pressure ulcers.
D. Hendrich II Scale:
The Hendrich II Fall Risk Model is a tool designed to identify patients at risk for falls. It includes factors such as confusion, symptomatic depression, altered elimination, dizziness, male gender, and the use of antiepileptics, benzodiazepines, or non-opioid analgesics. Similar to the Morse Scale, it focuses on assessing the risk of falls, not pressure ulcers.
Correct Answer is C
Explanation
A. Hypovolemic shock: Hypovolemic shock occurs when there is a significant loss of blood or fluids in the body, leading to insufficient blood volume to maintain normal circulation. Symptoms include rapid heart rate, low blood pressure, confusion, and cold, clammy skin. While hypovolemic shock is a concern in trauma patients, the symptoms described by the client (shortness of breath and chest pain) are not typical of hypovolemic shock.
B. Fat embolism syndrome: Fat embolism syndrome occurs when fat particles are released into the bloodstream, often after a long bone fracture or trauma. These fat particles can block small blood vessels, leading to symptoms such as respiratory distress, confusion, and petechial rash (small red or purple spots under the skin). While fat embolism syndrome is a concern in patients with long bone fractures, the symptoms described by the client are more suggestive of a pulmonary embolism.
C. Venous thromboembolism (VTE): VTE refers to the formation of blood clots in the veins. Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, usually in the legs, while pulmonary embolism (PE) occurs when a clot breaks loose and travels to the lungs. Symptoms of PE can include sudden chest pain, shortness of breath, rapid heart rate, and cough, which may produce bloody or blood-streaked sputum. Given the client's symptoms of shortness of breath and chest pain, VTE, specifically pulmonary embolism, is a significant concern.
D. Compartment syndrome: Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow and potential nerve damage. Symptoms can include severe pain, swelling, and numbness or tingling. While compartment syndrome is a complication of fractures, the symptoms described by the client (shortness of breath and chest pain) are not characteristic of compartment syndrome.
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