Question

The nurse is performing an abdominal assessment on a client. While the nurse is palpating the lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client complains of a sharp pain located in the right upper quadrant. How will the nurse document this finding in the medical record?

1) Positive Blumberg sign.
2) Presence of pain at McBurney point.
3) Positive Murphy sign.
4) Positive Psoas sign.

Answer 1

The nurse will document this finding as Positive Murphy sign in the medical record.

Step-by-step explanation:

The nurse will document this finding as Positive Murphy sign in the medical record.

Positive Murphy sign refers to the presence of pain in the right upper quadrant of the abdomen while the client takes a deep breath and holds it. This sign is suggestive of inflammation in the gallbladder or biliary system.

In the case of the client experiencing sharp pain during palpation of the lower border of the liver, it indicates a positive Murphy sign, which points to a potential gallbladder pathology.