The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Rigidity and firmness.

Sharp, severe pain.

Rebound tenderness.

Audible thud without pain.

Answer and Explanation

The Correct Answer is B

A. Rigidity and firmness. This is not typically expected; rigidity and firmness may indicate muscle spasm or guarding.

B. Sharp, severe pain. This is expected with pyelonephritis, as percussion over the inflamed kidney will elicit pain.

C. Rebound tenderness. Rebound tenderness is more indicative of peritoneal irritation rather than pyelonephritis.

D. Audible thud without pain. This is a normal finding; absence of pain does not align with the expected findings in pyelonephritis.

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Correct Answer is C

Explanation

A. Reading a short paragraph. Reading assesses cognitive function but not ADLs directly.

B. Telephoning a family member. This assesses communication skills but not practical ADLs.

C. Opening a bar soap package. This is the best choice because it directly assesses fine motor skills and the ability to perform a common ADL.

D. Sorting a collection of socks. Sorting socks assesses cognitive function and organization but not practical ADLs directly.

A. Capillary refill is measured in seconds B. Capillary refill is the time it takes to return to the client's normal color after releasing pressure C. Use your thumbnail and press the nailbed proximal to the injury D. Normal should be within 3 seconds or 5 in the older adult E. Pressure placed on the nailbed should cause blanching (pale)

Correct Answer is ["A","B","E"]

Explanation

A. Capillary refill is measured in seconds. This is correct. Capillary refill time is a measure of how quickly blood returns to the capillaries after pressure is applied and then released. It is typically measured in seconds.

B. Capillary refill is the time it takes to return to the client's normal color after releasing pressure. This is correct. Capillary refill time measures how quickly the color returns to the nailbed after pressure is applied. This indicates the adequacy of blood flow to the extremity.

C. Use your thumbnail and press the nailbed proximal to the injury. While you should press on the nailbed to assess capillary refill, it is generally recommended to use the pad of your thumb or finger rather than the thumbnail. Additionally, it's important to avoid pressing near the injury site if the area is bruised or painful, as this could distort the assessment.

D. Normal should be within 3 seconds or 5 in the older adult. A normal capillary refill time is generally within 2 seconds for adults. However, it can be up to 3 seconds in some clinical settings. For older adults, the time may be slightly longer, but 5 seconds is usually considered abnormal and may indicate poor perfusion.

E. Pressure placed on the nailbed should cause blanching (pale). This is correct. The application of pressure to the nailbed should cause blanching or paling of the area. The refill time is measured by how quickly the color returns to the nailbed once the pressure is released.

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The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

Correct Answer is C

Explanation

Patient Data Exhibits When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

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