Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with data collection of a client with suspected cholecystitis. Which finding does the nurse expect to note if cholecystitis is present?
A. Murphy sign
Reason: Murphy sign is a finding that indicates cholecystitis, which is inflammation of the gallbladder. It is elicited by palpating the right upper quadrant of the abdomen and asking the client to take a deep breath. The client will experience pain and stop breathing in if cholecystitis is present.
B. McBurney sign
Reason: McBurney sign is a finding that indicates appendicitis, which is inflammation of the appendix. It is elicited by palpating the right lower quadrant of the abdomen at a point one-third of the distance from the anterior superior iliac spine to the umbilicus. The client will experience pain and tenderness if appendicitis is present.
C. Cullen's sign
Reason: Cullen's sign is a finding that indicates intra-abdominal bleeding, which can be caused by various conditions such as ruptured ectopic pregnancy, pancreatitis, or trauma. It is characterized by bruising around the umbilicus due to blood accumulation under the skin.
D. Homan sign
Reason: Homan sign is a finding that indicates deep vein thrombosis (DVT), which is a blood clot in a deep vein, usually in the leg. It is elicited by dorsiflexing the foot and squeezing the calf muscle. The client will experience pain and resistance if DVT is present.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 3. Take the full exam now
Full Explanation
Choice A Reason: Murphy sign is a finding that indicates cholecystitis, which is inflammation of the gallbladder. It is elicited by palpating the right upper quadrant of the abdomen and asking the client to take a deep breath. The client will experience pain and stop breathing in if cholecystitis is present.
Choice B Reason: McBurney sign is a finding that indicates appendicitis, which is inflammation of the appendix. It is elicited by palpating the right lower quadrant of the abdomen at a point one-third of the distance from the anterior superior iliac spine to the umbilicus. The client will experience pain and tenderness if appendicitis is present.
Choice C Reason: Cullen's sign is a finding that indicates intra-abdominal bleeding, which can be caused by various conditions such as ruptured ectopic pregnancy, pancreatitis, or trauma. It is characterized by bruising around the umbilicus due to blood accumulation under the skin.
Choice D Reason: Homan sign is a finding that indicates deep vein thrombosis (DVT), which is a blood clot in a deep vein, usually in the leg. It is elicited by dorsiflexing the foot and squeezing the calf muscle. The client will experience pain and resistance if DVT is present.
Similar Questions
The nurse is participating in a care planning conference for a patient with acquired immunodeficiency syndrome (AIDS). What is the nurse's highest priority in providing care to this client?
A. Instituting measures to prevent infection.
Reason: Instituting measures to prevent infection is the highest priority in providing care to this client, as AIDS impairs the immune system and makes the client susceptible to opportunistic infections that can be life-threatening.
B. Providing emotional support.
Reason: Providing emotional support is an important aspect of providing care to this client, but it is not the highest priority, as it does not address the physical needs of the client.
C. Identifying risk factors related to contracting AIDS.
Reason: Identifying risk factors related to contracting AIDS is not relevant for providing care to this client, as it does not help to improve the current condition or prevent complications.
D. Discussing the cause of AIDS.
Reason: Discussing the cause of AIDS is not essential for providing care to this client, as it does not affect the treatment or prognosis of the disease.
Full Explanation
Choice A Reason: Instituting measures to prevent infection is the highest priority in providing care to this client, as AIDS impairs the immune system and makes the client susceptible to opportunistic infections that can be life-threatening.
Choice B Reason: Providing emotional support is an important aspect of providing care to this client, but it is not the highest priority, as it does not address the physical needs of the client.
Choice C Reason: Identifying risk factors related to contracting AIDS is not relevant for providing care to this client, as it does not help to improve the current condition or prevent complications.
Choice D Reason: Discussing the cause of AIDS is not essential for providing care to this client, as it does not affect the treatment or prognosis of the disease.
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Text 1:
A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?
A. Irrigate the fistula with 3 mL of normal saline solution.
Reason: Irrigating the fistula with 3 mL of normal saline solution is not a correct way to assess the patency of the fistula, as it may cause bleeding, infection, or dislodgement of the fistula.
B. Flush the fistula with 1 mL of heparin solution once per shift.
Reason: Flushing the fistula with 1 mL of heparin solution once per shift is not a correct way to assess the patency of the fistula, as it may cause clotting, infection, or allergic reaction.
C. Infuse 50 mL of normal saline once per 24 hours.
Reason: Infusing 50 mL of normal saline once per 24 hours is not a correct way to assess the patency of the fistula, as it may cause fluid overload, hypertension, or edema.
D. Palpate for a vibrating sensation at the fistula site.
Reason: Palpating for a vibrating sensation at the fistula site is a correct way to assess the patency of the fistula, as it indicates that there is adequate blood flow through the fistula. This sensation is also known as a thrill.
Full Explanation
Choice A Reason: Irrigating the fistula with 3 mL of normal saline solution is not a correct way to assess the patency of the fistula, as it may cause bleeding, infection, or dislodgement of the fistula.
Choice B Reason: Flushing the fistula with 1 mL of heparin solution once per shift is not a correct way to assess the patency of the fistula, as it may cause clotting, infection, or allergic reaction.
Choice C Reason: Infusing 50 mL of normal saline once per 24 hours is not a correct way to assess the patency of the fistula, as it may cause fluid overload, hypertension, or edema.
Choice D Reason: Palpating for a vibrating sensation at the fistula site is a correct way to assess the patency of the fistula, as it indicates that there is adequate blood flow through the fistula. This sensation is also known as a thrill.
A nurse is reinforcing teaching with a client who has cholecystitis about required dietary modifications. Which of the following food choices should the nurse inform the client to include in his diet?
A. Ice cream
Reason: Ice cream is not a good food choice for a client who has cholecystitis, as it is high in fat and may trigger gallbladder pain or inflammation.
B. Blueberry muffin
Reason: Blueberry muffin is not a good food choice for a client who has cholecystitis, as it may contain butter, oil, or eggs that are high in fat and may aggravate gallbladder symptoms.
C. Macaroni and cheese
Reason: Macaroni and cheese is not a good food choice for a client who has cholecystitis, as it is high in fat and cholesterol and may cause gallstone formation or obstruction.
D. Roast turkey
Reason: Roast turkey is a good food choice for a client who has cholecystitis, as it is low in fat and high in protein and may help to prevent gallbladder attacks.
Full Explanation
Choice A Reason: Ice cream is not a good food choice for a client who has cholecystitis, as it is high in fat and may trigger gallbladder pain or inflammation.
Choice B Reason: Blueberry muffin is not a good food choice for a client who has cholecystitis, as it may contain butter, oil, or eggs that are high in fat and may aggravate gallbladder symptoms.
Choice C Reason: Macaroni and cheese is not a good food choice for a client who has cholecystitis, as it is high in fat and cholesterol and may cause gallstone formation or obstruction.
Choice D Reason: Roast turkey is a good food choice for a client who has cholecystitis, as it is low in fat and high in protein and may help to prevent gallbladder attacks.
