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 B

Explanation

A. Diverticulosis: Murphy's sign is not used to diagnose diverticulosis.

B. Acute Cholecystitis: Murphy's sign is a clinical test used to identify acute cholecystitis. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.

C. Appendicitis: Murphy's sign is not associated with appendicitis; instead, other signs such as McBurney’s point tenderness are used.

D. Nephrolithiasis: Murphy's sign is not indicative of nephrolithiasis; kidney stones are assessed through other signs and symptoms.

A. Aortic murmurs B. Atrial repolarization C. The first heart sound D. Mitral stenosis

Correct Answer is D

Explanation

A. Aortic murmurs: These are best assessed with the client in an upright or slightly leaning forward position, not specifically the left lateral position.

B. Atrial repolarization: This is not directly assessed by body position; it is part of the ECG assessment.

C. The first heart sound: The first heart sound (S1) is heard throughout the auscultation process and is not specifically enhanced by a left lateral position.

D. Mitral stenosis: The left lateral position allows better auscultation of the mitral area, where mitral stenosis murmurs are best heard.

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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

A positive Murphy's sign is indicative of?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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