It is thought that a patient may be experiencing pancreatitis. Which nursing action would be useful in helping diagnose this disorder?
1. The patient bends the right knee and flexes the right hip, while the nurse flexes the thigh to a right angle and externally and internally rotates the leg.
2. The nurse inquires with radiology when an endoscopy can be scheduled for the patient.
3. The nurse anticipates that the patient's health care provider will order a barium enema.
4. Placing the hand on the lateral surface of the patient's flexed right thigh, the nurse asks the patient to push against the applied resistance.
4
Rationale 1: The obturator sign (painful external and internal rotation of a flexed hip and thigh) is positive in patients with inflammation along the obturator internus muscle. It is not a test for pancreatitis.
Rationale 2: Endoscopy allows the clinician to visualize the intraluminal space of the upper GI tract.
Rationale 3: A barium enema would enhance intraluminal processes such as colon cancer or diverticular disease.
Rationale 4: This option describes the iliopsoas sign test. A positive test (produces pain) indicates an inflammation of the iliopsoas muscle group. When there is intra-abdominal inflammation or disease of the pancreas or other structures, movement of the iliopsoas causes pain.
You might also like to view...
Which of the following is the greatest predictor of health status?
a. Literacy level b. Poverty c. Race or ethnicity d. Single parent households
A client with vaginitis complains of itching and burning of the perineum. Which suggestion would be most appropriate to relieve the client's symptoms?
A) Use a pure vinegar douche daily. B) Use skin protectants containing zinc oxide. C) Take sitz baths frequently. D) Avoid yogurt with active lactobacilli cultures.
During the assessment of a patient with thyroid dysfunction, the nurse notes hair loss and warm, moist skin. Which question is most important for the nurse to ask this patient?
1. "Have you experienced any recent weight loss?" 2. "Have you been feeling constipated?" 3. "Have you noticed increased bruising?" 4. "Have you noticed that you do not tolerate cold as well as you once did?"
When planning and providing care to a client of a different culture, the nurse utilizes techniques to enhance communication and implement appropriate and effective interactions
The nurse is utilizing the concepts of culturally competent care that are included in which of the following regulatory bodies' expectations? (Select all that apply.) 1. American Nurses Association Core Competencies 2. International Council of Nurses Code of Nursing 3. National Patient Safety Goals 4. Joint Commission standards 5. American Academy of Nursing Professional Responsibilities 6. American Nurses Association 1991 Position Statement