Author Question: The nurse is assessing a client in the emergency department (ED) who complains of right lower ... (Read 87 times)

krzymel · **on:** Jun 25, 2018

The nurse is assessing a client in the emergency department (ED) who complains of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign.

Based on the client's assessment data, which conditions does the nurse suspect?
Select all that apply.
1. Constipation.
2. Appendicitis.
3. Cholecystitis.
4. Small bowel obstruction.
5. Peritonitis.

Question 2

The client states, No one will let me eat or drink anything until after my test and it's been 9 hours since I last ate anything

While auscultating the client's abdomen the nurse hears frequent bowel sounds. How will the nurse document this finding in the medical record?
1. Borborygmi present.
2. Hypoactive bowel sounds present.
3. Bruit present.
4. Friction rub present.

lolol · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2, 5
A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation or appendicitis. Constipation is not typically associated with a positive psoas sign. The client with cholecystitis may exhibit a positive Murphy's sign. The client with a small bowel obstruction may exhibit abnormal bowel sounds.

Answer to Question 2

Correct Answer: 1
Normal bowel sounds occur every 5 to 15 seconds. Borborygmi are hyperactive bowel sounds that are most often auscultated in clients who have not eaten recently. Hypoactive bowel sounds are most often auscultated in clients who have had abdominal surgery or who have a bowel obstruction. A bruit is a pulsing, blowing sound that can be auscultated over arteries. A friction rub is a rough, grating sound caused by the rubbing together of organs or an organ rubbing on the peritoneum.