Author Question: The nurse is documenting the findings of an abdominal assessment on a client and documents the ... (Read 43 times)

lracut11 · **on:** Jun 25, 2018

The nurse is documenting the findings of an abdominal assessment on a client and documents the following information, pain noted during palpation at McBurney point. How did the nurse elicit this response during the assessment?

1. The nurse lightly palpated the around the client's umbilicus.
2. The nurse pressed into the client's abdomen and then pulled his hand back quickly.
3. The nurse palpated over the client's spleen.
4. The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.

Question 2

The nurse is completing an abdominal assessment and is percussing over the left side of the upper portion of the client's abdomen over the area of the stomach.

The client states, I haven't had my breakfast, yet. Based on this statement, which does the nurse anticipate?
1. Dullness.
2. Flatness.
3. Tympany.
4. Hyperesonance.

mmj22343 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 4
McBurney point is located 2.5 to 5.1 centimeters above the anterosuperior iliac spine, on a line between the ileum and the umbilicus. When the client experiences pain at this site with palpation it is referred to as a positive Rovsing sign, which is suggestive of peritoneal irritation that is most frequently associated with appendicitis. Pain with palpation over the umbilicus may indicate an infectious process such as diverticulitis. A hernia may be palpated or visualized during the nurse's inspection of the client's abdomen. Pain as an area is compressed and then is allowed to decompress is known as a positive Blumberg sign. This sign occurs in clients with peritoneal irritation. Normally, the client should feel pressure but no pain as the nurse palpates the client's spleen.

Answer to Question 2

Correct Answer: 3