When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

Rovsing sign

Obturator sign

Murphy sign

Psoas sign

Answer and Explanation

Correct Answer : A,B,D

A. Rovsing sign: This sign involves pain in the right lower quadrant when palpating the left lower quadrant, indicating appendicitis.

B. Obturator sign: Pain on internal rotation of the hip when the knee is flexed can indicate irritation of the appendix.

C. Murphy sign: This sign is used to assess for cholecystitis, not appendicitis.

D. Psoas sign: Pain with extension of the right leg can indicate irritation of the appendix due to the psoas muscle.

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Correct Answer is D

Explanation

A. Perform abdominal percussion, and then repeat auscultation: While percussion can provide additional information, the absence of bowel sounds should first be confirmed by listening for a longer period before moving to other techniques.

B. Palpate the client's abdomen to stimulate bowel motility: Palpation is not recommended to stimulate bowel sounds; it may alter the assessment.

C. Repeat auscultation in four to six hours: Immediate reassessment after five minutes of auscultation is preferable to prolonged waiting.

D. Listen for five minutes before documenting an absence of bowel sounds: To ensure accurate assessment, the nurse should listen for up to five minutes in each quadrant

A. Flat murmur B. Diastolic murmur C. Absent murmur D. Systolic murmur

Correct Answer is D

Explanation

A. A flat murmur does not accurately describe the type of murmur associated with mitral insufficiency.

B. Mitral insufficiency is typically classified as a systolic murmur, not diastolic.

C. An absent murmur would indicate no audible sound, which is not applicable here.

D. Mitral insufficiency or regurgitation is characterized by a systolic murmur due to the backflow of blood from the left ventricle into the left atrium during systole.

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When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Correct Answer is D

Explanation

A mitral insufficiency/regurgitation murmur is classified as:

Correct Answer is D

Explanation

While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate?

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

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