The nurse is documenting the findings of an abdominal assessment on a client and documents the following information, "pain noted during palpation at McBurney's point.". In which of the following ways did the nurse elicit this response?
1. The nurse lightly palpated the around the client's umbilicus.
2. The nurse pressed into the client's abdomen and then pulled his hand back quickly.
3. The nurse palpated over the client's spleen.
4. The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.
4
Rationale 1: The nurse should be able to lightly palpate around the umbilicus without any complaints of pain by the client.
Rationale 2: This procedure is used to elicit the Blumberg's sign.
Rationale 3: Palpation over the client's spleen may be used to determine if the client has splenomegaly.
Rationale 4: The nurse can palpate over McBurney's point to determine if the client has developed appendicitis.
You might also like to view...
A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, "I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!"
Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the client's refusal, and call the health care provider. d. Contact the provider to request an extra dose of the client's diuretic.
Which side effects are most common among patients receiving therapy with biological response modifiers (BRMs)?
a. Alopecia and bad breath b. Abdominal cramps and constipation c. Productive cough and wheezing d. Fever, chills, and flulike symptoms
When providing care to the Native American culture, it is important to elicit help from the
A) Spiritual healer B) Priestess C) Rabbi D) Preacher
A nursing instructor is reviewing the various theories related to anorexia nervosa. Which of the following would the instructor include when describing theories related to the biologic domain? Select all that apply
A) Genetic vulnerability B) Separation-individuation C) Role pressures D) Dieting leading to starvation E) Pursuit of thinness F) Decreased serotonin activity