A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

Positive skin hypersensitivity test.

Positive Rovsing sign.

Psoas sign.

Positive Obturator sign.

Answer and Explanation

The Correct Answer is B

A. Positive Skin Hypersensitivity Test: This is incorrect as it typically involves pain or discomfort with light touch, unrelated to rebound tenderness.

B. Positive Rovsing Sign: A positive Rovsing sign occurs when pain is felt in the right lower quadrant upon palpation of the left lower quadrant, indicating possible appendicitis.

C. Psoas Sign: This is elicited by extending the hip, and a positive sign indicates irritation of the iliopsoas muscle, often seen in appendicitis.

D. Positive Obturator Sign: This involves internal rotation of the hip, also used in appendicitis assessments but involves different positioning.

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Correct Answer is C

Explanation

A. 20: Incorrect, as it would imply a much higher dose.

B. 0.2: Incorrect, as this would be far too low.

C. 2: Phenytoin 0.2 g is equivalent to 200 mg (0.2 g x 1000 mg/g). Since each capsule is 100 mg, the nurse would need to administer 2 capsules (200 mg / 100 mg per capsule = 2).

D. 200: Incorrect, as 200 capsules would be an overdose.

A. At the symphysis pubis. B. In the left lower quadrant. C. At the umbilicus. D. In the right lower quadrant.

Correct Answer is A

Explanation

A. At the symphysis pubis: When the bladder is distended, it typically extends upward from the symphysis pubis. Therefore, the nurse should start palpation here to assess for bladder distention.

B. In the left lower quadrant: This location would be used to assess for structures like the descending colon or potential masses, not the bladder.

C. At the umbilicus: The bladder does not typically reach the umbilical region unless it is severely distended, making this less effective as a starting point.

D. In the right lower quadrant: This area is primarily used to assess structures such as the appendix or ascending colon, not the bladder.

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A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

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Naxlex Comprehensive Predictor Exams

The nurse receives the primary provider's order of phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer. (Round to the nearest whole number)

Correct Answer is C

Explanation

A client's bladder is found to be distended. At which location would the nurse begin palpating?

Correct Answer is A

Explanation

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