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Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1536). St. Louis: Saunders.Cognitive Ability: UnderstandingClient Needs: Health Promotion and MaintenanceIntegrated Process: Nursing Process/AssessmentContent Area: Health Assessment/Physical ExamAwarded 1.0 points out of 1.0 possible points.58.58.ID: 9477071115A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which of the following findings does the nurse expect to note if cholecystitis is present?A. Homan signB. Murphy sign CorrectC. Blumberg signD. McBurney signRationale: TheMurphy sign is an indicator of gallbladder disease. The client is asked to inhale while the examiner’s fingers are hooked under the liver border, at the bottom of the rib cage. Inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed. TheHoman sign is pain in the calf area on sharp dorsiflexion of the client’s foot. The Blumberg sign is thepresence of rebound tenderness on palpation of the abdomen. Rebound tenderness is a reliable sign of peritoneal irritation. The McBurney sign is a reaction of the client indicating severe pain and
extreme tenderness when the McBurney point (midway between the umbilicus and the anterior iliac crest in the right lower quadrant of the abdomen) is palpated. Such a reaction indicates appendicitis.Test-Taking Strategy: Specific knowledge regarding the physical assessment findings in the presence of cholecystitis is needed to answer this question. Visualizing the anatomic location of the gallbladder and recalling the definition of each sign in the options will direct you to the correct one. Review: the findings noted in cholecystitis and the signs noted in the options .Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1368). St. Louis: Saunders.Cognitive Ability: AnalyzingClient Needs: Health Promotion and MaintenanceIntegrated Process: Nursing Process/AssessmentContent Area: Adult Health/GastrointestinalAwarded 1.0 points out of 1.0 possible points.