Question

The nurse is documenting the findings of an abdominal assessment on a client and documents the following information, 'pain noted during palpation at McBurney point.' How did the nurse elicit this response during the assessment?

1) The nurse lightly palpated the area around the client's umbilicus.
2) The nurse pressed into the client's abdomen and then pulled his hand back quickly.
3) The nurse palpated over the client's spleen.
4) The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.

Answer 1

The nurse elicited pain at McBurney's point during an abdominal assessment by palpating the area between the ileum and umbilicus in the right lower quadrant, which is associated with appendicitis.

Step-by-step explanation:

The pain noted during palpation at McBurney's point is elicited by the nurse as follows: 'The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.'

McBurney's point corresponds with the location of the base of the appendix where it is attached to the cecum. It is roughly located one third of the distance from the anterior superior iliac spine to the umbilicus. This is a key area that health care providers examine when evaluating for appendicitis, which is characterized by tenderness in this area. The correct method of eliciting a response at McBurney's point is performed through palpation, not through superficial examination or rapid retraction of the hand as in rebound tenderness tests.