While conducting an abdominal physical examination, the client complains of pain with deep palpation of the right kidney. Which of the following should be the nurse's next step in the physical examination?

Light palpation of the abdominal right lower quadrant

Auscultate sounds in the abdominal left lower quadrant

Deep palpation of the abdominal left upper quadrant

First percussion of the costovertebral angles

Answer and Explanation

The Correct Answer is D

A) Light palpation of the abdominal right lower quadrant: While light palpation is generally the first step in an abdominal examination to assess for tenderness or abnormalities, the presence of pain with deep palpation of the right kidney indicates a more specific concern. This may warrant further investigation related to the kidney rather than focusing on the lower quadrant.
B) Auscultate sounds in the abdominal left lower quadrant: Auscultation is typically done before palpation to assess bowel sounds and other abnormalities. However, given the specific complaint of pain in the right kidney area, the priority should be addressing the suspected kidney issue rather than auscultating another quadrant.
C) Deep palpation of the abdominal left upper quadrant: Deep palpation in another quadrant is not immediately relevant to the complaint of pain in the right kidney. Instead, it’s crucial to focus on assessing the area directly related to the client's symptoms.
D) First percussion of the costovertebral angles: Percussion of the costovertebral angles (CVA) is a specific technique used to assess kidney tenderness and is appropriate for evaluating the potential causes of the pain in the right kidney. This examination can help determine if the pain is due to conditions like kidney infection or inflammation. Therefore, it is the most relevant next step in this situation.

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Correct Answer is B

Explanation

A) 20 represents the distance a normal eye can read and 40 represents the distance your eye read the chart: This option incorrectly reverses the interpretation of the numbers. The correct interpretation is that the first number represents the distance at which the patient is reading the chart, and the second number represents the distance at which a person with normal vision would be able to read the same line.
B) 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye read the chart: This is the correct interpretation of visual acuity. In the Snellen chart system, the first number (20) represents the distance (in feet) from which the patient is viewing the chart, while the second number (40) represents the distance at which a person with normal vision (20/20) would be able to read the same line of the chart.
C) 20 represents the distance you are placed from the chart and 40 represents the distance your eye read the chart: This option is incorrect because it does not accurately describe what the numbers mean. The second number represents the distance at which normal vision can read the line, not the distance the patient’s eye read the chart.
D) 40 represents the distance you are placed from the chart and 20 represents the distance normal eye read the chart: This option incorrectly assigns the numbers. The distance of 20 feet is standard for testing vision, and 40 feet is the benchmark for normal vision. The correct understanding is that 20 is the test distance, and 40 is the comparison distance for normal vision.

A. Background B. Person C. Situation D. Place E. Time

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

Explanation

A) Background: Orientation to "background" is not a standard component of the "AOX3" (alert and oriented times three) assessment. Typically, orientation assessments focus on more specific elements such as person, place, and time, rather than background information.
B) Person: Orientation to "person" means that the patient is aware of who they are. This is a key aspect of the AOX3 assessment, which checks whether the patient can identify themselves correctly.
C) Situation: While awareness of the situation or current circumstances is important, "situation" is not included in the standard AOX3 assessment. The usual components are person, place, and time.
D) Place: Orientation to "place" means the patient knows where they are. This is a critical component of the AOX3 assessment, indicating that the patient can identify their current location.
E) Time: Orientation to "time" means that the patient is aware of the current date, day of the week, and time of day. This is another essential part of the AOX3 assessment, reflecting the patient's awareness of the temporal context.

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While conducting an abdominal physical examination, the client complains of pain with deep palpation of the right kidney. Which of the following should be the nurse's next step in the physical examination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

Correct Answer is B

Explanation

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

Explanation

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