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. Diaphragm on one side, bell on the opposite side: Suitable for a full cardiac examination, as it can assess both high and low-frequency sounds.

B. Diaphragm Only: Less suitable for a full cardiac examination because it may not effectively capture low-frequency sounds such as certain heart murmurs.

C. Bell on one side, Diaphragm on the opposite side: Effective for a full cardiac examination, as it can assess both high and low-frequency sounds.

D. Diaphragm and bell on same side: Allows for a complete assessment of heart sounds, though it may be less versatile than separate components on each side.

A. Percuss, inspect, auscultate, palpate B. Auscultate, inspect, palpate, percuss C. Palpate, percuss, inspect, auscultate D. Inspect, auscultate, percuss, palpate

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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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

Of the four types of stethoscopes, which one is most unsuitable to conduct a full cardiac examination?

Correct Answer is B

Explanation

A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Correct Answer is D

Explanation

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