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 C

Explanation

A) Hypoxia: Although the client's oxygen saturation is slightly decreased at 95% on room air, it is not critically low. Hypoxia could be a concern, but it is secondary to other more immediate issues, such as hypotension, that might be causing the low oxygen saturation.
B) Anemia: The client’s hemoglobin and hematocrit levels are low, indicating anemia. While anemia is a significant concern, it does not pose an immediate threat compared to hypotension, which can lead to more severe complications if not addressed promptly.
C) Hypotension: The client’s blood pressure is notably low at 82/58 mm Hg. Hypotension can lead to inadequate perfusion of vital organs and may be a result of or contribute to other issues such as sepsis or significant blood loss. Immediate attention to correcting hypotension is crucial to prevent further complications.
D) Pneumonia: The client presents with symptoms suggestive of pneumonia, including a productive cough, fever, and elevated white blood cell count. While pneumonia is a critical condition that requires treatment, addressing hypotension is a more urgent priority as it directly impacts the client's circulatory stability and overall well-being.

A. XI B. VIII C. IX D. X

Correct Answer is B

Explanation

A) XI: Cranial nerve XI, the spinal accessory nerve, is primarily responsible for motor function, particularly in the muscles involved in shoulder elevation and head rotation. It does not play a role in balance, so focusing on this nerve would not be relevant to the client’s complaint of balance issues.
B) VIII: Cranial nerve VIII, the vestibulocochlear nerve, is directly involved in hearing and balance. It transmits information from the inner ear to the brain regarding head position and motion, which are essential for maintaining balance. The client’s report of spontaneous loss of balance strongly suggests involvement of this nerve, making it the most appropriate focus for additional assessment.
C) IX: Cranial nerve IX, the glossopharyngeal nerve, is primarily associated with taste and the gag reflex. While it is important for swallowing and certain aspects of speech, it does not influence balance, so it would not be the primary concern in this situation.
D) X: Cranial nerve X, the vagus nerve, has extensive functions related to autonomic control of the heart, lungs, and digestive tract, as well as motor and sensory functions in the throat. Although it plays a significant role in the body, it does not directly influence balance, making it less relevant in this 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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

Correct Answer is B

Explanation

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