Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A positive Murphy's sign is indicative of?
A. Diverticulosis
Diverticulosis: Murphy's sign is not used to diagnose diverticulosis.
B. Acute Cholecystitis
Acute Cholecystitis: Murphy's sign is a clinical test used to identify acute cholecystitis. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.
C. Appendicitis
Appendicitis: Murphy's sign is not associated with appendicitis; instead, other signs such as McBurney’s point tenderness are used.
D. Nephrolithiasis
Nephrolithiasis: Murphy's sign is not indicative of nephrolithiasis; kidney stones are assessed through other signs and symptoms.
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Full Explanation
A. Diverticulosis: Murphy's sign is not used to diagnose diverticulosis.
B. Acute Cholecystitis: Murphy's sign is a clinical test used to identify acute cholecystitis. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.
C. Appendicitis: Murphy's sign is not associated with appendicitis; instead, other signs such as McBurney’s point tenderness are used.
D. Nephrolithiasis: Murphy's sign is not indicative of nephrolithiasis; kidney stones are assessed through other signs and symptoms.
Similar Questions
During the physical assessment of the peripheral vascular system, a client's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this client is at risk for developing:
A. Venous insufficiency ulcers
Venous insufficiency ulcers: Typically present with dark discoloration and edema, but not specifically with changes in color with elevation and dependency.
B. Arterial insufficiency ulcers
Arterial insufficiency ulcers: Pale feet when elevated and dark red when dependent are classic signs of arterial insufficiency. These changes in color are due to poor blood flow.
C. Neuropathic ulcers
Neuropathic ulcers: Usually associated with diabetes and often occur on pressure points, not typically related to color changes with elevation.
D. Deep vein thrombosis
Deep vein thrombosis: While DVT can cause swelling and pain, it does not usually present with color changes that are dependent on the position of the foot.
Full Explanation
A. Venous insufficiency ulcers: Typically present with dark discoloration and edema, but not specifically with changes in color with elevation and dependency.
B. Arterial insufficiency ulcers: Pale feet when elevated and dark red when dependent are classic signs of arterial insufficiency. These changes in color are due to poor blood flow.
C. Neuropathic ulcers: Usually associated with diabetes and often occur on pressure points, not typically related to color changes with elevation.
D. Deep vein thrombosis: While DVT can cause swelling and pain, it does not usually present with color changes that are dependent on the position of the foot.
During the cardiac cycle heart sounds correlate with events of the cycle. Which is being associated with systole?
A. S3
S3: This sound is associated with early diastole, often related to heart failure or volume overload.
B. S1
S1: The first heart sound (S1) marks the beginning of systole and corresponds to the closure of the mitral and tricuspid valves.
C. S2
S2: The second heart sound (S2) indicates the end of systole and the beginning of diastole, associated with the closure of the aortic and pulmonic valves.
D. S4
S4: This sound is associated with late diastole, often related to decreased ventricular compliance.
Full Explanation
A. S3: This sound is associated with early diastole, often related to heart failure or volume overload.
B. S1: The first heart sound (S1) marks the beginning of systole and corresponds to the closure of the mitral and tricuspid valves.
C. S2: The second heart sound (S2) indicates the end of systole and the beginning of diastole, associated with the closure of the aortic and pulmonic valves.
D. S4: This sound is associated with late diastole, often related to decreased ventricular compliance.
Aortic insufficiency/regurgitation murmur is classified as a:
A. Systolic murmur
Systolic murmur: Systolic murmurs occur during systole and include conditions like aortic stenosis or mitral regurgitation.
B. Diastolic murmur
Diastolic murmur: Aortic insufficiency/regurgitation occurs during diastole when the aortic valve fails to close properly, allowing blood to flow back into the left ventricle.
C. Absent murmur
Absent murmur: Aortic insufficiency/regurgitation is not classified as absent; it is detectable with auscultation.
D. Very faint murmur
Very faint murmur: Although aortic regurgitation murmurs can vary in intensity, the classification pertains to the timing of the murmur, not its loudness.
Full Explanation
A. Systolic murmur: Systolic murmurs occur during systole and include conditions like aortic stenosis or mitral regurgitation.
B. Diastolic murmur: Aortic insufficiency/regurgitation occurs during diastole when the aortic valve fails to close properly, allowing blood to flow back into the left ventricle.
C. Absent murmur: Aortic insufficiency/regurgitation is not classified as absent; it is detectable with auscultation.
D. Very faint murmur: Although aortic regurgitation murmurs can vary in intensity, the classification pertains to the timing of the murmur, not its loudness.