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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Perform abdominal percussion, and then repeat auscultation: While percussion can provide additional information, the absence of bowel sounds should first be confirmed by listening for a longer period before moving to other techniques.

B. Palpate the client's abdomen to stimulate bowel motility: Palpation is not recommended to stimulate bowel sounds; it may alter the assessment.

C. Repeat auscultation in four to six hours: Immediate reassessment after five minutes of auscultation is preferable to prolonged waiting.

D. Listen for five minutes before documenting an absence of bowel sounds: To ensure accurate assessment, the nurse should listen for up to five minutes in each quadrant

A. Systolic murmur B. Diastolic murmur C. Absent murmur D. Very faint murmur

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Correct Answer is D

Explanation

Aortic insufficiency/regurgitation murmur is classified as a:

Correct Answer is B

Explanation

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