The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply)
Test for the Murphy sign
Test for shifting dullness
Perform the obturator test
Test for the Blumberg sign
Perform the iliopsoas muscle test
Test for fluid wave
Correct Answer : C,D,E
A. Murphy sign: This is used to assess for gallbladder inflammation, not appendicitis.
B. Shifting dullness: This is used to detect ascites, not appendicitis.
C. Obturator test: This test involves flexing the patient's right hip and knee and rotating the leg internally, causing pain if the appendix is inflamed.
D. Blumberg sign: This test for rebound tenderness indicates peritoneal irritation, commonly associated with appendicitis.
E. Iliopsoas muscle test: This test involves extending the right leg against resistance, which can elicit pain in cases of appendicitis.
F. Fluid wave: This is used to assess for ascites, not appendicitis.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Smallest speculum: The smallest speculum may not provide the best view of the ear canal and tympanic membrane, especially in adults. The correct size should be chosen for adequate visualization.
B. Releasing the traction: Traction should be maintained to stabilize the ear and allow a better view of the ear canal.
C. Tilting the person's head forward: This is not the ideal positioning for the ear examination. The head should be tilted slightly away to straighten the ear canal.
D. Pulling the pinna up and back: This helps straighten the ear canal, especially in adults, providing better visualization during the otoscopic examination.
Correct Answer is A
Explanation
A. Shine a light across the pupil from the side: To assess the pupillary light reflex, the nurse should shine a light across the pupil from the side and observe for both direct and consensual constriction (the constriction of both pupils when one is exposed to light).
B. Follow the penlight: This tests for accommodation (focusing on near objects) rather than the pupillary light reflex.
C. Shine a penlight directly in front: This method doesn’t assess both direct and consensual constriction properly.
D. Focus on a distant object: This assesses accommodation, not the pupillary light reflex.
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