The nurse is assessing a client in the emergency department (ED) who complains of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign
Based on the client's assessment data, which conditions does the nurse suspect?
Select all that apply.
1. Constipation.
2. Appendicitis.
3. Cholecystitis.
4. Small bowel obstruction.
5. Peritonitis.
Correct Answer: 2, 5
A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation or appendicitis. Constipation is not typically associated with a positive psoas sign. The client with cholecystitis may exhibit a positive Murphy's sign. The client with a small bowel obstruction may exhibit abnormal bowel sounds.
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The mother of a cancer patient comes to the nurse concerned with her daughter's safety; the morphine dose she needs to control her pain is getting "higher and higher." The mother is afraid that her daughter will overdose
The nurse educates the mother to the fact that: A) The dose range is higher with cancer patients and we will be very careful to prevent addiction. B) Frequently, women need higher doses of morphine to be comfortable. C) Cancer is a terminal illness that requires higher doses of narcotics. D) There is no maximum opioid dose and your daughter is just becoming more tolerant to the drug.
When the skin of the anterior chest stays pinched for a few seconds during a client's admission assessment, how should this finding be documented?
a. "dehydrated" c. "loose skin-turgor" b. "fair hydration" d. "normal hydration"
A pediatric nurse is doing her initial shift assessments on assigned patients. One of the patient's is a toddler with pneumonia. How would the nurse assess this patient's skin turgor?
A) Pinch a fold of skin on the patient's abdomen B) Pinch a fold of skin on the patient's cheek C) Pinch a fold of skin on the patient's upper thigh D) Pinch a fold of skin on the patient's forearm
A postoperative patient visits the ambulatory care clinic complaining of just "not feeling well." The patient has an elevated temperature
As the nurse assesses the surgical wound, an indication that the wound has become infected is that the wound: A. culture is negative. B. has no odor. C. edges reveal the presence of fluid. D. shows purulent drainage coming from the incision area.