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.
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.
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