The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant. Which assessment should the nurse conduct next?
Palpate at McBurney's point for rebound tenderness.
Assess for Murphy's sign.
Assess for Tinel sign.
Test for a fluid wave.
The Correct Answer is A
A. Palpating McBurney's point for rebound tenderness helps evaluate for appendicitis, which is relevant given the client’s localized tenderness in the right lower quadrant.
B. Murphy's sign is used to assess for gallbladder inflammation, which is not indicated by right lower quadrant pain.
C. The Tinel sign is used to assess for nerve irritation, not abdominal pain or appendicitis.
D. Testing for a fluid wave is used to assess for ascites, which does not fit the presentation of localized right lower quadrant pain.
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Related Questions
Correct Answer is D
Explanation
A. Gallops refer to abnormal heart sounds that occur during the cardiac cycle, not typically associated with sounds over the carotid artery.
B. Murmurs are abnormal heart sounds that occur due to turbulent blood flow in the heart, not typically related to the carotid artery.
C. Normal findings would not usually include high-pitched swooshing sounds over the carotid artery; such sounds are abnormal.
D. Bruits are abnormal sounds caused by turbulent blood flow in the arteries, which can be detected as high-pitched swooshing sounds over the carotid artery, often indicative of stenosis or narrowing of the vessel.
Correct Answer is D
Explanation
A. Percuss, inspect, auscultate, palpate: This sequence is incorrect because inspection should be performed first to assess the abdomen visually.
B. Auscultate, inspect, palpate, percuss: This sequence is incorrect because auscultation should follow inspection and before palpation and percussion.
C. Palpate, percuss, inspect, auscultate: This sequence is incorrect as palpation and percussion should not come before inspection.
D. Inspect, auscultate, percuss, palpate: This is the correct sequence. Inspection is first, followed by auscultation to listen to bowel sounds, then percussion to assess for fluid or gas, and finally palpation to check for tenderness or masses.
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