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.
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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Related Questions
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.
Correct Answer is D
Explanation
A. Dextrocardia is a condition where the heart is located on the right side of the chest and does not typically cause crackles in the lungs.
B. Hypertension may lead to cardiovascular complications but is not directly associated with crackles in the lungs.
C. Palpitations are related to sensations of irregular or rapid heartbeats, not crackles in the lungs.
D. Fine crackles in the lungs are often associated with left-sided heart failure due to fluid accumulation in the lungs from compromised cardiac function.
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