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. Percussion, inspection, palpation, auscultation: This sequence could disturb bowel sounds by percussing before auscultation, making it difficult to assess them accurately.

B. Inspection, palpation, percussion, auscultation: Palpating before auscultating can alter bowel sounds, so it’s not the correct order.

C. Inspection, auscultation, percussion, palpation: This sequence is recommended for abdominal assessment to avoid altering bowel sounds. Inspection is done first to observe any visible abnormalities, followed by auscultation to listen to bowel sounds before palpating or percussing, which could disrupt the sounds.

D. Auscultation, inspection, palpation, percussion: Inspection should always be first, making this option incorrect as it begins with auscultation.

A. A client who has pneumonia B. A client who has shigella C. A client who has strep throat D. A client who has tuberculosis

Correct Answer is D

Explanation

A. A client who has pneumonia: Pneumonia typically requires droplet precautions, not airborne.

B. A client who has shigella: Shigella is transmitted through the fecal-oral route, so contact precautions would be appropriate.

C. A client who has strep throat: Streptococcal infections are spread by droplets, so droplet precautions are indicated, not airborne.

D. A client who has tuberculosis: Tuberculosis (TB) is spread via airborne droplets, so airborne precautions are necessary to prevent transmission.

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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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Explanation

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Explanation

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