A nurse is caring for a client with acute pyelonephritis. Which area should the nurse percuss to assess for pain related to pyelonephritis?
McBurney's point on the abdomen
Psoas sign at the knee
Rovsing's Sign on the abdomen
costovertebral angle (CVA) on the back
The Correct Answer is D
A. McBurney's point on the abdomen: McBurney's point is a location in the right lower quadrant of the abdomen that is significant in the assessment for appendicitis. It is not relevant to the assessment of pyelonephritis, which is a kidney infection.
B. Psoas sign at the knee: The psoas sign is a test for appendicitis, not pyelonephritis. It involves the patient lying on their back and lifting their right leg against resistance. If this movement causes pain in the lower right abdomen, it could indicate irritation of the psoas muscle due to an inflamed appendix.
C. Rovsing's Sign on the abdomen: Rovsing's sign is also a test for appendicitis. It involves palpating the left lower quadrant of the abdomen and observing if it causes pain in the right lower quadrant. The presence of pain in the right lower quadrant during palpation of the left lower quadrant can indicate appendicitis. This sign is not specific to pyelonephritis.
D. Costovertebral angle (CVA) on the back: The CVA is located on the back at the angle formed by the 12th rib and the spine. Percussion of the CVA is a common technique used to assess for kidney tenderness. In the case of acute pyelonephritis, infection and inflammation of the kidneys can cause tenderness and pain in the CVA area. Therefore, this area is assessed for pain related to kidney infections like pyelonephritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased urinary output: Phenazopyridine (Pyridium) does not directly impact urinary output. Its primary function is to provide relief from urinary pain, burning, and discomfort associated with urinary tract infections (UTIs) or other urinary conditions. It does not affect the amount of urine a person produces.
B. Decreased WBC's: Phenazopyridine does not directly influence white blood cell count (WBCs). WBC count is an indicator of the body's immune response and is typically used to assess the presence of infection. Phenazopyridine provides symptomatic relief but does not affect the underlying infection or the body's immune response to it.
C. Increased uric acid: Phenazopyridine does not affect uric acid levels. Uric acid is a waste product that is excreted by the kidneys. Elevated uric acid levels can be associated with conditions like gout, but Phenazopyridine does not have any direct impact on these levels.
D. Decreased bladder pain/spasms: Phenazopyridine is intended to relieve symptoms such as bladder pain, spasms, burning sensation, and discomfort experienced during urination. Therefore, the effectiveness of Phenazopyridine is indicated by a reduction in these symptoms. If the patient reports a decrease in bladder pain and spasms, it suggests that the medication is working to alleviate the discomfort associated with urinary tract issues.
Correct Answer is D
Explanation
A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.
B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.
C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.
D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.
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