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?
Audible thud without pain.
Sharp, severe pain.
Rebound tenderness.
Rigidity and firmness.
The Correct Answer is B
Choice A rationale
An audible thud without pain is a normal finding when percussing the costovertebral angle (CVA) in a healthy individual. This indicates that there is no inflammation or infection in the kidneys or surrounding tissues.
Choice B rationale
Sharp, severe pain upon percussion of the CVA is a classic sign of pyelonephritis. This pain is due to the inflammation and infection of the kidney, which causes tenderness in the area.
Choice C rationale
Rebound tenderness is typically associated with peritoneal irritation, such as in cases of appendicitis or peritonitis. It is not a common finding in pyelonephritis.
Choice D rationale
Rigidity and firmness are more indicative of muscle spasms or guarding, which can occur in conditions like peritonitis or severe abdominal pain, but not specifically in pyelonephritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Measuring skin elasticity around the ankles is not directly related to assessing the cause of cold feet. It is more relevant for assessing hydration status and skin turgor.
Choice B rationale
Assessing the volume of the pedal pulses is crucial to determine if there is adequate blood flow to the feet.
Choice C rationale
Palpating the dorsal surface of the feet for warmth helps assess the temperature and circulation to the feet.
Choice D rationale
Testing for a positive Babinski reflex is not relevant to assessing cold feet. It is used to assess neurological function.
Choice E rationale
Observing the color of the feet and toes helps assess circulation and potential issues such as cyanosis or pallor.
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