A nurse is assisting with data collection of a client with suspected cholecystitis. Which finding does the nurse expect to note if cholecystitis is present?
Murphy sign
McBurney sign
Cullen's sign
Homan sign
The Correct Answer is A
Choice A Reason: Murphy sign is a finding that indicates cholecystitis, which is inflammation of the gallbladder. It is elicited by palpating the right upper quadrant of the abdomen and asking the client to take a deep breath. The client will experience pain and stop breathing in if cholecystitis is present.
Choice B Reason: McBurney sign is a finding that indicates appendicitis, which is inflammation of the appendix. It is elicited by palpating the right lower quadrant of the abdomen at a point one-third of the distance from the anterior superior iliac spine to the umbilicus. The client will experience pain and tenderness if appendicitis is present.
Choice C Reason: Cullen's sign is a finding that indicates intra-abdominal bleeding, which can be caused by various conditions such as ruptured ectopic pregnancy, pancreatitis, or trauma. It is characterized by bruising around the umbilicus due to blood accumulation under the skin.
Choice D Reason: Homan sign is a finding that indicates deep vein thrombosis (DVT), which is a blood clot in a deep vein, usually in the leg. It is elicited by dorsiflexing the foot and squeezing the calf muscle. The client will experience pain and resistance if DVT is present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Calling the RN supervisor is not the priority action for the nurse, as it may delay the intervention and outcome.
Choice B Reason: Completing an incident report is not the priority action for the nurse, as it does not address the immediate problem or prevent further complications.
Choice C Reason: Checking the blood glucose level is not the priority action for the nurse, as it may confirm the error but not correct it.
Choice D Reason: Giving the client 15 to 20 g of carbohydrate is the priority action for the nurse, as it may prevent or treat hypoglycemia, which is a serious complication of insulin overdose.
Correct Answer is C
Explanation
Choice A Reason: Drinking white wine, not red, is not an indication that the client understands the instructions, as both types of wine are high in purine and may trigger gout attacks.
Choice B Reason: Limiting the number of fruit servings I eat each day is not an indication that the client understands the instructions, as most fruits are low in purine and may help to lower uric acid levels.
Choice C Reason: Avoiding eating organ meats is an indication that the client understands the instructions, as organ meats are very high in purine and may increase uric acid levels and cause gout flare-ups.
Choice D Reason: Choosing red meat instead of poultry is not an indication that the client understands the instructions, as both red meat and poultry are high in purine and may worsen gout symptoms.
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