The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:
Examine the tender area last.
Palpate the tender area first, and then auscultate for bowel sounds.
Avoid palpating the tender area.
Examine the tender area first.
The Correct Answer is A
Abdominal assessment requires a strict sequence of inspection, auscultation, percussion, and palpation to prevent iatrogenic alteration of bowel sounds. Palpating painful areas last prevents voluntary guarding and muscle rigidity that could obscure clinical findings. This ensures a reliable physical examination of the peritoneum.
A. Examine the tender area last: Assessing non-tender quadrants first allows the patient to relax and prevents early muscle tensing. This technique ensures that the nurse can accurately identify the boundaries of pain and masses. It is the standard clinical protocol for localized pain.
B. Palpate the tender area first, and then auscultate for bowel sounds: Palpation before auscultation can stimulate peristalsis and create false bowel sounds or worsen the patient's pain immediately. This sequence violates the standard abdominal examination order. It reduces the diagnostic accuracy of the assessment.
C. Avoid palpating the tender area: Complete omission of palpation prevents the clinician from identifying rebound tenderness or masses like an inflamed appendix. While light palpation is preferred initially, the area must be assessed to determine the severity. Total avoidance leads to incomplete data.
D. Examine the tender area first: Leading the examination with the painful area causes immediate discomfort and protective guarding across the entire abdomen. This makes it impossible to assess other quadrants effectively. It disrupts the patient-provider rapport and physical relaxation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Anosmia, the loss of olfaction, results from dysfunction of the olfactory nerve, which transmits sensory data from the nasal epithelium. It is the shortest cranial nerve and passes through the cribriform plate of the ethmoid bone. Damage often occurs via head trauma, viral infections, or anterior fossa tumors.
A. IX: The glossopharyngeal nerve mediates taste for the posterior third of the tongue and the gag reflex. It provides secretomotor fibers to the parotid gland and visceral sensory input from the carotid sinus. It does not contribute to the sense of smell.
B. I: Cranial nerve I is the olfactory nerve, purely responsible for the special visceral afferent pathway of smell. Clinical assessment involves testing each nostril with non-irritating odors like coffee. This nerve is the direct anatomical structure responsible for the patient's symptoms.
C. XII: The hypoglossal nerve is a purely motor nerve that innervates the extrinsic and intrinsic muscles of the tongue. Assessment involves observing for tongue deviation, fasciculations, or atrophy during protrusion. It has no sensory function related to olfaction or chemicals.
D. X: The vagus nerve provides extensive parasympathetic innervation to the thoracic and abdominal viscera and controls phonation and swallowing. It carries sensory information from the larynx and pharynx. It is not involved in the special sensory process of smelling.
Correct Answer is D
Explanation
Phalen's test assesses for median nerve compression within the carpal tunnel. Sustained hyperflexion increases interstitial pressure, eliciting paresthesia or hypoesthesia in the lateral 3.5 digits. This clinical diagnostic tool identifies carpal tunnel syndrome resulting from tenosynovitis or anatomical narrowing.
A. Tinel's sign: Percussion of the volar carpal ligament elicits distal tingling or electric shock sensations in the median nerve distribution. This maneuver identifies nerve irritability rather than compression from sustained flexion. It serves as a secondary clinical indicator for focal entrapment.
B. Allen test: This vascular assessment evaluates the patency of the radial and ulnar arteries supplying the palmar arch. Compression and release of these vessels demonstrate collateral circulation through skin reperfusion. It is not used for neurological or sensorimotor nerve entrapment.
C. Finkelstein test: Passive ulnar deviation of the wrist with the thumb flexed into the palm identifies de Quervain tenosynovitis. This maneuver stretches the abductor pollicis longus and extensor pollicis brevis tendons. It focuses on stenosing tenosynovitis rather than carpal nerve compression.
D. Phalen's test: Maintaining 90 degree wrist flexion for 60 seconds mechanically constricts the carpal tunnel. The resulting ischemia triggers tingling in the thumb, index, and middle fingers. This positive finding specifically correlates with the entrapment of the median nerve described.
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