The nurse is performing an abdominal assessment on a client. ...

[faduma]

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.

[CourtneyCNorton]

Answer to Question 1

Correct Answer: 3
Pain with palpation of the liver is indicative of cholecystitis and is noted as a positive Murphy's sign. The examination should be halted. Blumberg sign is sharp pain occurring with the release of a compressed area and is present when the client has peritoneal irritation. Pain at McBurney point in the right lower quadrant is associated with appendicitis. Pain that is elicited while flexing the hip is indicative of psoas muscle irritation and is associated with peritoneal inflammation or appendicitis.

Answer to Question 2

Correct Answer: 4

This client most likely is experiencing diverticulitis. The client's white blood cell count, temperature, and blood pressure are elevated as a result of the infection. High-fiber food intake can be a precipitating factor. Lying down after meals is often associated with gastroesophageal reflux disorder. Caffeine intake is associated with irritable bowel syndrome. Drinking alcohol is associated with irritable bowel syndrome and pancreatitis.

[faduma]

Correct answers!

[CourtneyCNorton]

Great! Please up vote