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?

Sharp, severe pain.

Audible thud without pain.

Rigidity and firmness.

Rebound tenderness.

Answer and Explanation

The Correct Answer is A

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Abduct each hip while the client is supine:
While assessing hip abduction can provide information about hip joint mobility, it may not be the most appropriate initial assessment for hip dysfunction. This action primarily evaluates the range of motion but may not specifically target dysfunction in the hip region.

B) Flex the hip and knee while standing:
Flexing the hip and knee while the client is standing can help assess hip function, particularly in weight-bearing positions. This action can reveal limitations in hip mobility and detect dysfunction such as pain or weakness during movement.

C) Observe balance while the client stands:
Observing balance while the client stands is important for assessing overall lower extremity function, including the hips. However, it may not specifically target dysfunction in the hip region and may provide more general information about mobility and stability.

D) Inspect gluteal folds for symmetry:
Inspecting gluteal folds for symmetry can help identify asymmetry or abnormalities in the hip region, but it may not provide direct information about hip dysfunction. This action is more focused on assessing external appearance rather than functional movement or mobility.

A. Left carotid artery has strong pulse; right carotid artery occluded. B. Left carotid pulse volume of 4+; right carotid pulse volume of 0. C. Left carotid artery occlusion present; no occlusion of right carotid artery. D. Left carotid artery bruit present; no bruit heard in right carotid artery.

Correct Answer is D

Explanation

A) Left carotid artery has strong pulse; right carotid artery occluded:
This documentation is incorrect because the presence of a bruit does not indicate a strong pulse or occlusion. A bruit suggests turbulent blood flow, often due to partial obstruction or narrowing of the artery, not necessarily a strong pulse or complete occlusion.

B) Left carotid pulse volume of 4+; right carotid pulse volume of 0:
This documentation focuses on the pulse volume rather than the presence of a bruit. The nurse's assessment was related to auscultation findings (bruit) rather than palpation findings (pulse volume).

C) Left carotid artery occlusion present; no occlusion of right carotid artery:
A bruit indicates turbulent blood flow, which may be due to partial obstruction, but it does not confirm complete occlusion. Therefore, this documentation would be inaccurate.

D) Left carotid artery bruit present; no bruit heard in right carotid artery:
This documentation accurately reflects the nurse's findings. A bruit is a blowing, swishing sound indicating turbulent blood flow, often due to narrowing or partial obstruction of the artery. Documenting the presence of a bruit provides essential information for further evaluation and management.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

Correct Answer is B

Explanation

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Correct Answer is D

Explanation

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?