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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Flatness: This percussion note is typically associated with areas of high density, such as over muscle or a solid organ like the liver. In a pneumothorax, the lung tissue is not solidified, so flatness is not expected.
B. Dullness: Dullness is generally noted over fluid-filled areas or solid structures, such as a pleural effusion or a mass. In the case of a pneumothorax, where there is air in the pleural space, dullness would not be the expected finding.
C. Resonance: Resonance is the normal percussion note over healthy lung tissue. It indicates normal air-filled lung spaces. In a pneumothorax, the increased air in the pleural space causes an abnormal note.
D. Hyperresonance: This percussion note is associated with increased air in the pleural space, as seen in conditions like a pneumothorax. The extra air causes a more resonant, hollow sound when percussed, distinguishing it from normal lung resonance.

A. Background B. Person C. Situation D. Place E. Time

Correct Answer is ["B","D","E"]

Explanation

A) Background: Orientation to "background" is not a standard component of the "AOX3" (alert and oriented times three) assessment. Typically, orientation assessments focus on more specific elements such as person, place, and time, rather than background information.
B) Person: Orientation to "person" means that the patient is aware of who they are. This is a key aspect of the AOX3 assessment, which checks whether the patient can identify themselves correctly.
C) Situation: While awareness of the situation or current circumstances is important, "situation" is not included in the standard AOX3 assessment. The usual components are person, place, and time.
D) Place: Orientation to "place" means the patient knows where they are. This is a critical component of the AOX3 assessment, indicating that the patient can identify their current location.
E) Time: Orientation to "time" means that the patient is aware of the current date, day of the week, and time of day. This is another essential part of the AOX3 assessment, reflecting the patient's awareness of the temporal context.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is diagnosed with a Pneumothorax on the right lung. During the assessment, when percussing this area the nurse expects to find the percussion note as:

Correct Answer is D

Explanation

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Correct Answer is ["B","D","E"]

Explanation

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