Which assessment finding alerts the nurse to the likelihood that the patient has a distended bladder?
1. Percussion in the middle of the lower abdomen elicits a dull sound.
2. The patient states, "My back is killing me.".
3. Percussion over the costovertebral angle produces pain.
4. The patient complains of colicky pain in the side.
1
Rationale 1: Percussion over a full bladder produces a dull percussion sound.
Rationale 2: Kidney pain is experienced in the back and the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Discomfort from a distended bladder would more likely be felt elsewhere.
Rationale 3: Pain elicited by percussion over the costovertebral angle is likely due to kidney damage or infection.
Rationale 4: Colicky pain may be due to a kidney stone.
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