A nurse is performing a focused abdominal assessment on a child complaining of stomach pain. Which assessment finding warrants immediate action by the nurse?
A.
Complains of pain of 4 on 1-10 scale
B.
Lack of rebound tenderness
C.
Negative obturator sign
D.
Positive heel-drop jarring test
ANS: D
A positive heel-drop jarring test involves having the patient stand on his or her toes for 15 seconds then drop onto the heels. Pain elicited with this assessment is indicative of appendicitis. The patient may also wince when getting off the examination table. The nurse should notify the provider immediately. Pain is nonspecific and needs treatment, but does not need immediate action. A negative obturator sign is normal, as is the lack of rebound tenderness.
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