The nurse is performing an abdominal assessment on a client. While the nurse is palpating the lower border of the liver, the nurse asks the client to take a deep breath and hold it.
The client complains of a sharp pain located in the right upper quadrant. How will the nurse document this finding in the medical record?
1. Positive Blumberg sign.
2. Presence of pain at McBurney point.
3. Positive Murphy sign.
4. Positive Psoas sign.
Question 2
The client was recently admitted to the hospital with left lower quadrant pain. The client states, It feels like my belly is cramping. During the focused interview, the client admitted to experiencing a significant amount of occupational stress.
Guarding is noted during the abdominal examination. The nurse reviews the medical record (see chart below) and concludes that the client has developed a diverticulitis. Which client statement supports this conclusion by the nurse?
Assessment or diagnostic test Results
White blood cell count 25,000/mm3
Red blood cell count 4.2 x 1012/L
Temperature 101.2 degrees Fahrenheit
Blood pressure 152/84
1. I get home so late at night, but I've got to stop lying down right after dinner.
2. I drink a whole pot of coffee every day.
3. I drink 9-12 beers after I get home from work, every day.
4. We have been growing green beans in our garden and I think I ate too many the other day.
NURSE CARING BEHAVIORS AS
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