The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Notify the healthcare provider of the rebound tenderness.

Obtain a prescription to catheterize the client's bladder.

Offer to administer a laxative prescribed for PRN use.

Instruct the client in distraction and relaxation techniques.

Answer and Explanation

The Correct Answer is A

A) Notify the healthcare provider of the rebound tenderness:
Rebound tenderness, also known as Blumberg's sign, is a clinical sign that suggests peritoneal irritation, which can be indicative of underlying pathology such as peritonitis. Reporting rebound tenderness to the healthcare provider is crucial for further evaluation and management of the client's condition.

B) Obtain a prescription to catheterize the client's bladder:
While urinary retention can present with lower abdominal discomfort, the scenario described does not specifically suggest urinary retention. Catheterization should be considered based on additional assessments and indications related to urinary symptoms, not solely based on the client's report of pain upon release of abdominal pressure.

C) Offer to administer a laxative prescribed for PRN use:
Administering a laxative would not be appropriate based solely on the client's report of pain upon release of abdominal pressure. Laxatives are indicated for constipation, which may cause abdominal discomfort, but they would not address rebound tenderness or the underlying cause of the client's pain.

D) Instruct the client in distraction and relaxation techniques:
While distraction and relaxation techniques can be helpful for managing pain, they would not address the underlying cause of rebound tenderness. Reporting rebound tenderness to the healthcare provider is necessary for further evaluation and appropriate management.

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Correct Answer is A

Explanation

A) Sharp, severe pain:
Percussion of the costovertebral angle (CVA) elicits sharp, severe pain in a client with pyelonephritis. This response indicates inflammation of the kidney and surrounding tissues, which is typical in pyelonephritis.

B) Audible thud without pain:
An audible thud without pain is a normal finding when percussing the CVA and would not be expected in a client with pyelonephritis.

C) Rigidity and firmness:
Rigidity and firmness may be related to muscle guarding or abdominal assessment findings, but they are not specific to CVA percussion and pyelonephritis.

D) Rebound tenderness:
Rebound tenderness is a sign of peritoneal irritation and is assessed by pressing on the abdomen and quickly releasing. It is not the typical finding associated with CVA percussion in pyelonephritis.

A. Deep, continuous pain in the calf muscles. B. Painful symptoms alleviated by warmth. C. Cool, pale skin below the knees. D. Decreased pain when legs are elevated.

Correct Answer is D

Explanation

A. Deep, continuous pain in the calf muscles:
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

B. Painful symptoms alleviated by warmth:
Painful symptoms alleviated by warmth are more characteristic of arterial insufficiency, such as in peripheral arterial disease (PAD), rather than venous insufficiency.

C. Cool, pale skin below the knees:
Cool, pale skin below the knees is also more suggestive of arterial insufficiency rather than venous insufficiency. Arterial insufficiency often presents with decreased blood flow to the extremities, resulting in coolness and pallor.

D. Decreased pain when legs are elevated:
This is the correct answer. Venous insufficiency typically results in symptoms such as aching, tired legs, and swelling, which worsen with prolonged standing but improve with leg elevation. This is due to the reduction in venous pressure when the legs are elevated, which helps alleviate symptoms associated with venous congestion and stasis.

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The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is A

Explanation

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Correct Answer is D

Explanation

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