How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?
Percuss between the iliac crest and ribs at the midaxillary line.
Push fingers upward into the two lowest intercostal spaces.
Palpate along both sides of the lumbar vertebral column.
Strike a flat hand covering the costovertebral angle (CVA).
The Correct Answer is D
Choice A rationale
Percussion between the iliac crest and ribs at the midaxillary line is not the standard method for assessing flank tenderness associated with pyelonephritis. This technique may not elicit the characteristic pain of kidney inflammation.
Choice B rationale
Pushing fingers upward into the two lowest intercostal spaces is not a specific test for flank tenderness and may not accurately assess for pyelonephritis. This action is more related to assessing the integrity of the rib cage and intercostal muscles.
Choice C rationale
Palpating along both sides of the lumbar vertebral column is not the correct method for assessing flank tenderness due to pyelonephritis. This approach is more suited for assessing the musculoskeletal structure rather than the kidneys.
Choice D rationale
Striking a flat hand over the costovertebral angle is the correct method for assessing flank tenderness in cases of suspected pyelonephritis. This technique, known as costovertebral angle tenderness, elicits pain when the kidneys are inflamed, which is a common sign of pyelonephritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A regular diet with no added salt may not be sufficient to address the fluid retention associated with acute glomerulonephritis and peripheral edema.
Choice B rationale
While a low-protein, low-potassium diet may be considered for certain kidney conditions, it does not specifically address the fluid and sodium management needed in acute glomerulonephritis with edema.
Choice C rationale
A low-carbohydrate, low-protein diet is not indicated in this scenario as it does not provide the necessary restrictions on sodium and fluid that are required for a child with edema and oliguria due to acute glomerulonephritis.
Choice D rationale
A low-sodium, fluid-restricted diet is most appropriate for a child with acute glomerulonephritis and peripheral edema. This diet helps manage the edema and prevent further fluid overload, which is crucial in the care of this condition.
Correct Answer is D
Explanation
Choice A rationale
Jaundice of the sclera is indicative of hyperbilirubinemia, which can occur in various liver diseases but is not specifically associated with Grey Turner's sign or pancreatitis.
Choice B rationale
Bluish discoloration of the periumbilical area, known as Cullen's sign, is another indicator of severe pancreatitis but is distinct from Grey Turner's sign, which specifically refers to the flank area.
Choice C rationale
Left abdominal pain that occurs with movement may be a symptom experienced by patients with pancreatitis, but it is not referred to as Grey Turner's sign, which is a physical finding rather than a symptom.
Choice D rationale
Grey Turner's sign is characterized by bluish discoloration of the flank area. It is a sign of retroperitoneal hemorrhage, which can occur in severe cases of pancreatitis due to the spread of pancreatic enzymes to surrounding tissues, leading to localized bleeding.
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