While conducting an abdominal physical examination, the client complains of pain with deep palpation of the right kidney. Which of the following should be the nurse's next step in the physical examination?
Light palpation of the abdominal right lower quadrant
Auscultate sounds in the abdominal left lower quadrant
Deep palpation of the abdominal left upper quadrant
First percussion of the costovertebral angles
The Correct Answer is D
A) Light palpation of the abdominal right lower quadrant: While light palpation is generally the first step in an abdominal examination to assess for tenderness or abnormalities, the presence of pain with deep palpation of the right kidney indicates a more specific concern. This may warrant further investigation related to the kidney rather than focusing on the lower quadrant.
B) Auscultate sounds in the abdominal left lower quadrant: Auscultation is typically done before palpation to assess bowel sounds and other abnormalities. However, given the specific complaint of pain in the right kidney area, the priority should be addressing the suspected kidney issue rather than auscultating another quadrant.
C) Deep palpation of the abdominal left upper quadrant: Deep palpation in another quadrant is not immediately relevant to the complaint of pain in the right kidney. Instead, it’s crucial to focus on assessing the area directly related to the client's symptoms.
D) First percussion of the costovertebral angles: Percussion of the costovertebral angles (CVA) is a specific technique used to assess kidney tenderness and is appropriate for evaluating the potential causes of the pain in the right kidney. This examination can help determine if the pain is due to conditions like kidney infection or inflammation. Therefore, it is the most relevant next step in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Weber test: The Weber test is used to assess hearing by placing a vibrating tuning fork on the center of the forehead. It helps evaluate lateralization of sound and can indicate whether hearing loss is conductive or sensorineural. This test is pertinent for assessing CN VIII, which is responsible for hearing.
B. Magazine: This option is not relevant to the assessment of CN VIII. A magazine is not used in evaluating hearing or vestibular function. The appropriate assessments for CN VIII focus on hearing and balance.
C. Rinne test: The Rinne test involves placing a vibrating tuning fork on the mastoid bone and then near the ear canal to compare air conduction (AC) and bone conduction (BC) of sound. This test helps differentiate between conductive and sensorineural hearing loss and is directly related to assessing CN VIII.
D. Whispered voice test: This test involves the nurse whispering numbers or words while occluding one ear and assessing the client's ability to hear and repeat them. It is a simple way to assess hearing ability and thus evaluates the function of CN VIII.
Correct Answer is "{\"xRanges\":[104.828125,113.828125],\"yRanges\":[122.5,131.5]}"
Explanation
To auscultate the apical pulse, the nurse should place the stethoscope at the fifth intercostal space, midclavicular line on the left side of the chest. This location is where the apex of the heart is closest to the chest wall, making it the best spot for assessing the apical pulse.
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