A nurse is assessing a client suspected of having acute cholecystitis. Which of the following techniques should the nurse use to elicit Boas' sign?
Percussion of the left lower quadrant
Deep palpation of the epigastric region
Palpation of the right upper quadrant during inspiration
Auscultation of the left upper quadrant
The Correct Answer is C
Choice A reason:
Percussion of the left lower quadrant is not relevant to assess for Boas' sign, which involves the right upper quadrant.
Choice B reason:
Deep palpation of the epigastric region is not associated with Boas' sign. Boas' sign involves palpation of the right subscapular area.
Choice C reason:
This statement is correct. Boas' sign is elicited by palpating the right upper quadrant during inspiration. The client may experience referred pain to the right subscapular area, indicating irritation of the phrenic nerve by the inflamed gallbladder.
Choice D reason:
Auscultation of the left upper quadrant is not relevant to assessing for Boas' sign, which involves the right upper quadrant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This question is relevant to assess for gastrointestinal symptoms, as changes in bowel movements may indicate issues with digestion or absorption.
Choice B reason:
Family history of heart disease is not directly related to peptic ulcer disease. However, it is essential for overall health assessment and risk factor identification.
Choice C reason:
Swelling or edema in the legs may be indicative of cardiovascular or circulatory issues, but it is not directly related to peptic ulcer disease.
Choice D reason:
The frequency of consuming high-fiber foods is not specifically related to peptic ulcer disease. However, diet history is essential for overall health assessment.
Correct Answer is C
Explanation
Choice A reason:
Elevated white blood cell count may indicate inflammation or infection, but it is not directly related to jaundice and dark-colored urine, which are characteristic of increased bilirubin levels.
Choice B reason:
Impaired blood clotting is not directly related to jaundice and dark-colored urine. It may be a concern in liver disease but does not explain the specific manifestations mentioned in the question.
Choice C reason:
This statement is correct. Jaundice and dark-colored urine are indicative of increased bilirubin levels in the blood, which can occur in cholecystitis due to obstruction of the bile ducts.
Choice D reason:
Elevated serum amylase is more associated with pancreatitis rather than cholecystitis. It is not directly related to the clinical manifestations described.
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