You believe your patient has cholescystitis. You've called the physician to let them know, and she asks you if the patient has a positive Murphy's sign. What will you need to do to find out if the patient has a positive Murphy's sign?

 

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Correct

- Place your hand below the patient's costal margin on the right side, at the midclavicular line. Ask the patient to breathe in. If patient is unable to breathe in due to pain, the test is considered positive.

- Hold the knee flexed 45 degrees. Place one hand on the medial aspect of the knee and pull laterally. Use your other hand to rotate the knee in, and if a click is heard or pain is experienced, the test is considered positive.

- Lightly tap their facial nerve. If any twitching occurs, the test is positive.

- Tenderness at the point over the right side of the abdomen that is 1/3 of the distance from the anterior superior iliac spine to the navel.

Rationale

Being unable to breathe in due to pain is a positive Murphy's sign. The examine with the knee is a positive McMurray test. Tapping the facial nerve and noting twitching is Chvostek sign. Tenderness at the point over the right side of the abdomen that is 1/3 of the distance from the anterior superior iliac spine to the navel is McBurney's point.

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Question Information

Nursing Category

GI / GU

Question Difficulty
Total - 213
Correct - 107
Percent Right - 50.234741784
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Question ID - 368409

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