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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is ["A","B","D"]
Explanation
A. Rovsing sign: This sign involves pain in the right lower quadrant when palpating the left lower quadrant, indicating appendicitis.
B. Obturator sign: Pain on internal rotation of the hip when the knee is flexed can indicate irritation of the appendix.
C. Murphy sign: This sign is used to assess for cholecystitis, not appendicitis.
D. Psoas sign: Pain with extension of the right leg can indicate irritation of the appendix due to the psoas muscle.
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