A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?
Positive skin hypersensitivity test.
Positive Rovsing sign.
Psoas sign.
Positive Obturator sign.
The Correct Answer is B
A. Positive Skin Hypersensitivity Test: This is incorrect as it typically involves pain or discomfort with light touch, unrelated to rebound tenderness.
B. Positive Rovsing Sign: A positive Rovsing sign occurs when pain is felt in the right lower quadrant upon palpation of the left lower quadrant, indicating possible appendicitis.
C. Psoas Sign: This is elicited by extending the hip, and a positive sign indicates irritation of the iliopsoas muscle, often seen in appendicitis.
D. Positive Obturator Sign: This involves internal rotation of the hip, also used in appendicitis assessments but involves different positioning.
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Correct Answer is C
Explanation
A. The client is terminally ill: DPOA is not automatically activated by terminal illness but by the client’s inability to communicate.
B. The client is incapable of providing self-care: This alone does not activate the DPOA unless they are also unable to make healthcare decisions.
C. The client is unable to express their wishes: Durable power of attorney for healthcare decisions is activated when the client becomes unable to make or communicate their healthcare choices.
D. The client has refused treatment: Refusal of treatment is a decision that an alert and capable client can make independently.
Correct Answer is C
Explanation
A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.
B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.
C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.
D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.