which of the following symptoms best describes murphys sign
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. Which of the following symptoms best describes Murphy’s sign?

Correct answer: C

Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.

2. Which of the following complications is thought to be the most common cause of appendicitis?

Correct answer: A

Rationale: A fecalith is a hardened stool that can block the appendix, leading to inflammation and infection, which is the most common cause of appendicitis.

3. The home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need

Correct answer: A

Rationale: A lack of intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

4. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of

Correct answer: C

Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.

5. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?

Correct answer: B

Rationale: Covering the wound with a saline soaked sterile dressing is the most appropriate intervention for wound evisceration.

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