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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Systolic murmur: Systolic murmurs occur during systole and include conditions like aortic stenosis or mitral regurgitation.
B. Diastolic murmur: Aortic insufficiency/regurgitation occurs during diastole when the aortic valve fails to close properly, allowing blood to flow back into the left ventricle.
C. Absent murmur: Aortic insufficiency/regurgitation is not classified as absent; it is detectable with auscultation.
D. Very faint murmur: Although aortic regurgitation murmurs can vary in intensity, the classification pertains to the timing of the murmur, not its loudness.
Correct Answer is C
Explanation
A. ST segment: Represents the period between ventricular depolarization and repolarization.
B. QRS complex: Represents ventricular depolarization.
C. T wave: Indicates ventricular repolarization, or relaxation, after the QRS complex.
D. P wave: Represents atrial depolarization.
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