The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant. Which assessment should the nurse conduct next?

Palpate at McBurney's point for rebound tenderness.

Assess for Murphy's sign.

Assess for Tinel sign.

Test for a fluid wave.

Answer and Explanation

The Correct Answer is A

A. Palpating McBurney's point for rebound tenderness helps evaluate for appendicitis, which is relevant given the client’s localized tenderness in the right lower quadrant.

B. Murphy's sign is used to assess for gallbladder inflammation, which is not indicated by right lower quadrant pain.

C. The Tinel sign is used to assess for nerve irritation, not abdominal pain or appendicitis.

D. Testing for a fluid wave is used to assess for ascites, which does not fit the presentation of localized right lower quadrant pain.

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Correct Answer is C

Explanation

A. Pulmonic and tricuspid: The tricuspid valve's closure is not primarily audible at the 2nd intercostal space right sternal border; it is better heard at the lower left sternal border.

B. Mitral and aortic: The mitral valve is best heard at the apex of the heart, not the 2nd intercostal space right sternal border.

C. Aortic and pulmonic: The 2nd intercostal space right sternal border is the area where the aortic and pulmonic valves are auscultated. The louder S2 here indicates the closure of these valves, with the aortic valve being the primary source of sound in this area.

D. Tricuspid and mitral: These valves are best heard at other locations, with the tricuspid valve near the lower left sternal border and the mitral valve at the apex.

A. Diverticulosis B. Acute Cholecystitis C. Appendicitis D. Nephrolithiasis

Correct Answer is B

Explanation

A. Diverticulosis: Murphy's sign is not used to diagnose diverticulosis.

B. Acute Cholecystitis: Murphy's sign is a clinical test used to identify acute cholecystitis. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.

C. Appendicitis: Murphy's sign is not associated with appendicitis; instead, other signs such as McBurney’s point tenderness are used.

D. Nephrolithiasis: Murphy's sign is not indicative of nephrolithiasis; kidney stones are assessed through other signs and symptoms.

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The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant. Which assessment should the nurse conduct next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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