Abdomen Assessment
A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regards to this finding? a) "How many times have you been pregnant?" b) "Do you have high blood pressure?" c) "Have you noticed any color change to the skin?" d) "Are you experiencing any abdominal pain?"
"How many times have you been pregnant?" Explanation: Striae are silvery white marks that are common on the abdomen from stretching of the skin during pregnancy or weight gain. They do not cause pain or any other color changes to the skin. High blood pressure may cause the dilation of the superficial arterioles or capillaries with a central star pattern (spider angioma) but would not result in striae.
A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining if this client is truly experiencing an alteration in bowel pattern? a) "Have you changed your food intake this week?" b) "How many times a day are you having a bowel movement?" c) "What is the consistency of your stools??" d) "Do you have a bowel movement every day?"
"How many times a day are you having a bowel movement?" Explanation: Diarrhea is defined as frequency of bowel movements producing unformed or liquid stools. To determine if the client is truly experiencing diarrhea, the nurse should ask about how many times a day the client is having a bowel movement. The other important question is how many times a day does the client normally have a bowel movement. The consistency will not tell the nurse whether this is normal or abnormal. Asking about food intake will give information about whether the client has tried to treat the problem
A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says a) "I should cut down on the number of iron tablets I am taking each day." b) "Constipation should decrease if I take the iron tablets with milk." c) "I can decrease the constipation if I eat foods high in fiber and drink water." d) "I should discontinue the iron tablets and eat foods that are high in iron."
"I can decrease the constipation if I eat foods high in fiber and drink water." Explanation: High iron intake may lead to chronic constipation. Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 479.
The nurse suspects an abdominal aortic aneurysm when what is assessed? a) Abdominal bruit b) Increased femoral pulses c) Warm extremities d) Hypertension
Abdominal bruit Explanation: Auscultation of the abdomen would reveal a bruit. The client may exhibit decreased femoral pulses, hypotension and cool extremities.
Which of the following assessment findings would need to be reported the physician immediately? a) Absent bowel sounds, vomiting undigested food b) Chest fullness, heartburn and nausea after eating c) Diarrhea and flatus d) Constipation
Absent bowel sounds, vomiting undigested food Explanation: Absent bowel sounds, vomiting undigested food is abnormal and may indicate a bowel obstruction. Constipation, Chest fullness, heartburn and nausea after eating. diarrhea and flatus do are not as high of a priority.
A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action? a) Ask about pertinent risk factors. b) Document a detailed health history. c) Ask the client when the pain began. d) Obtain a 24 hour diet recall.
Ask the client when the pain began. Explanation: If a patient has an acute abdominal problem, the history and physical examination will be focused on that problem, so that much of the history taking will be eliminated. Severe dehydration from nausea and vomiting, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Pain is the chief complaint and should be assessed before a diet recall, obtaining a health history, and identifying risk factors
A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend? a) Avoid eating overcooked foods b) Avoid taking pain medications with food c) Avoid taking antacid medications d) Avoid excessive alcohol intake
Avoid excessive alcohol intake Explanation: The nurse should recommend avoiding excessive alcohol intake, as this is a risk factor associated with peptic ulcer disease. The nurse should also recommend eating foods that have been cooked completely and taking pain medications with food. Antacid medications may relieve peptic ulcers
While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound? a) Erratic b) Borborygmus c) Hypoactive d) Absent
Borborygmus Explanation: The nurse should find that bowel sounds are absent in a client with paralytic ileus. Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds. Hyperactive bowel sounds may be caused by diarrhea, gastroenteritis, and early bowel obstruction. Hypoactive bowel sounds may be due to surgery or late bowel obstruction. Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling." Erratic is not a type of bowel sound.
When palpating a client's liver, the nurse feels a firm edge. What would this indicate to the nurse? a) Cirrhosis b) Splenomegaly c) Calcification of the liver d) Liver failure
Cirrhosis Explanation: Abnormal liver findings include hepatomegaly and the firm edge of cirrhosis. A firm edge does not indicate liver failure or calcification. Splenomegaly is a distractor for this question.
A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client? a) Ineffective Health Maintenance b) Constipation related to decrease in fluid intake c) Risk for Fluid Volume Deficit d) Ineffective Nutrition: Less Than Body Requirements
Constipation related to decrease in fluid intake Explanation: The nurse can confirm constipation because the major defining characteristics of decreased frequency and abdominal discomfort are present. A few days of altered nutrition does not meet the necessary criteria to confirm Ineffective Nutrition or Risk for Fluid Volume Deficit. Ineffective Health Maintenance cannot be confirmed because there is no evidence that the client lacks the knowledge to eat properly
A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? a) Gastric ulcer b) Pancreatitis c) Gastroesophageal reflux d) Crohn's disease
Crohn's disease Explanation: Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine
A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? a) Gastroesophageal reflux b) Crohn's disease c) Pancreatitis d) Gastric ulcer
Crohn's disease Explanation: Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine
The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant? a) Rub b) Hollow tympanic notes c) Dullness d) Hum
Dullness Explanation: Normal percussion findings include dullness over the liver in the RUQ and hollow tympanic notes in the LUQ over the gastric bubble. Hums and rubs are ausculatory sounds.
On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity? a) Fluid accumulation b) Obstruction c) Inflammation d) Bleeding
Fluid accumulation Explanation: Pale and taut skin indicates significant abdominal swelling caused by accumulation of fluid in the abdominal cavity, or ascites. Bleeding within the abdominal wall would manifest as purple discoloration at the flanks. Inflammation of the peritoneum and obstruction of the intestine does not contribute to pale and taut abdominal skin.
Which of the following people need to be vaccinated for hepatitis A and B? a) Animal care workers b) Food-service workers c) Office personnel d) Truck drivers
Food-service workers Explanation: Hepatitis A and B immunizations are recommended for all infants; people whose work may expose them to blood, body fluids, or unsanitary conditions (i.e., health care, food services, sex workers); and those traveling to parts of the world where these illnesses are prevalent.
A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause? a) Gastric ulcer b) Crohn's disease c) Gastroesophageal reflux d) Pancreatitis
Gastric ulcer Explanation: Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.
A client complains of abdominal pain that is worsened when he lies on his back. The nurse should suspect which of the following as the underlying cause? a) Pancreatitis b) Gastroesophageal reflux c) Gastric ulcer d) Crohn's disease
Gastroesophageal reflux Explanation: Gastroesophageal reflux is worsened when supine. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Pancreatitis is worsened with alcohol ingestion.
A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause? a) Escherichia coli b) Streptococcus pyogenes c) Staphylococcus aureus d) Helicobacter pylori
Helicobacter pylori Explanation: Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucous, on occasion the H. pylori disrupt the mucous lining and inflame the organ lining. The other bacteria listed are not associated with peptic ulcer disease
Nursing students are learning how to identify different areas of the abdomen. What is the lower middle area called? a) Hypogastric b) Hypochondriac c) Inogastric d) Epigastric
Hypogastric Explanation: The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbical, left lumbar, right inguinal, hypogastric, and left inguinal.
Which is the proper sequence of examination for the abdomen? a) Auscultation, percussion, inspection, palpation b) Inspection, percussion, palpation, auscultation c) Auscultation, inspection, palpation, percussion d) Inspection, auscultation, percussion, palpation
Inspection, auscultation, percussion, palpation Explanation: The abdominal examination is conducted in a sequence different from other systems. Usually the order is inspection, percussion, palpation, then auscultation. Because palpation may actually cause some bowel noise when the bowels are not moving, auscultation is performed before percussion and palpation.
A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following? a) Linea alba b) Peritoneum c) Internal abdominal oblique d) Transverse abdominis
Linea alba Explanation: The joining of the muscle fibers and aponeuroses at the midline of the abdomen forms a white line called the linea alba, which extends vertically from the xiphoid process of the sternum to the symphysis pubis. The abdomen includes three layers of muscle extending from the back, around the flanks, to the front. The outermost layer is the external abdominal oblique; the middle layer is the internal abdominal oblique; and the innermost layer is the transverse abdominis. A thin, shiny, serous membrane called the peritoneum lines the abdominal cavity (parietal peritoneum) and also provides a protective covering for most of the internal abdominal organs (visceral peritoneum).
A nurse auscultates for bowels sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after one minute. What is an appropriate action by the nurse? a) Listen for a total of five (5) minutes b) Document the absence of bowel sounds c) Palpate for abdominal rigidity d) Assess for findings of dehydration
Listen for a total of five (5) minutes Explanation: Bowel sounds normally occur every 5 to 15 seconds. In a client with nausea and vomiting, bowel sounds may be hypoactive. The nurse should listen for a total of 5 minutes to confirm the absence of bowel sounds. Assessing the client for dehydration is necessary but not in relation to the finding of bowel sounds. Palpation should be done after completing auscultation of the abdomen.
Your patient describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your patient? a) Crohn disease b) Ulcerative colitis c) Lactose intolerance d) Malabsorption syndrome
Malabsorption syndrome Explanation: Malabsorption syndrome is characterized by stool that is typically bulky, soft, light yellow to gray, mushy, greasy or oily, sometimes frothy, and particularly foul-smelling, and it usually floats in the toilet.
A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement? a) Auscultate for bowel sounds b) Measure abdominal girth c) Perform percussion for tympany d) Palpate the abdomen
Measure abdominal girth Explanation: The nurse should measure abdominal girth daily to assess changes in abdominal distension. Palpating and auscultating the abdomen may not give relevant information about peritonitis. Percussion for tympany may indicate presence of air but does not indicate improvement.
During the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign? a) Rovsing's b) Obturator c) Psoas d) Murphy's
Murphy's Explanation: Murphy's sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. The obturator sign involves pain in the right lower quadrant as a result of the nurse flexing the client's hip and rotating the leg externally and internally while supporting the client's right knee and ankle. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.
Mr. Martin is a 72-year-old smoker who comes to the clinic for a follow-up visit for hypertension. With deep palpation a pulsatile mass about 4 cm in diameter is palpable. What should the examiner do next? a) Refer to a vascular surgeon. b) Reassess by examination in 3 months. c) Reassess by examination in 6 months. d) Obtain abdominal ultrasound.
Obtain abdominal ultrasound. Explanation: A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 cm. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature.
How should the nurse perform blunt percussion over the liver? a) Place left hand on right lower rib cage, strike it with ulnar side of right fist b) Place left hand on right lower rib cage, strike it with radial side of right fist c) Place right hand on mid of the rib cage; strike it with ulnar side of left fist d) Place right hand on mid of the rib cage; strike it with ulnar side of left fist
Place left hand on right lower rib cage, strike it with ulnar side of right fist Explanation: The correct way of performing blunt percussion is to place left hand on right lower rib cage, strike it with ulnar side of right fist. Placing the hand on the mid of rib cage would not enable the nurse to assess the liver. Placing the right hand on the rib cage and striking with radial side of left hand may not be technically possible.
The nurse correctly identifies the gallbladder is located where? a) RUQ b) RLQ c) LUQ d) LLQ
RUQ The gallbladder is located in the right upper quadrant of the abdomen. Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 23: Assessing Abdomen, pg. 475.
A client complains of a sudden onset of pain in the back. On questioning the client further, the nurse learns that the cause of the pain is acute pancreatitis. The nurse recognizes that this type of pain is which of the following? a) Referred pain b) Radiated pain c) Chronic pain d) Localized pain
Referred pain Explanation: Pancreatic inflammation, or pancreatitis, may be felt in the back. This is called "referred" pain because the pain is not felt at its source. This is not radiated pain, which extends continuously to the tissues surrounding the source, nor is it localized pain, which remains only in one small area. It is not chronic pain, as it results from acute pancreatitis.
As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? a) Right lower quadrant b) Left lower quadrant c) Right upper quadrant d) Left upper quadrant
Right upper quadrant Explanation: The liver is the largest solid organ in the body. It is located below the diaphragm in the right upper quadrant of the abdomen.
Which nursing diagnosis is most appropriate for an elderly client with poor dentition? a) Risk for Imbalanced Nutrition: Less Than Body Requirements b) Constipation c) Diarrhea d) Fluid volume deficit
Risk for Imbalanced Nutrition: Less Than Body Requirements Explanation: A client with poor dentition is at risk for Imbalanced Nutrition: Less Than Body Requirements as teeth may be missing or chewing may be difficult. None of the other diagnosis are related to poor dentition.
The nurse is caring for a client suffering from a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part? a) Oropharynx b) Descending colon c) Small intestine d) Esophagus
Small intestine Explanation: Absorption of nutrients takes place almost exclusively in the small intestine. The esophagus propels the food bolus by means of slow peristaltic movements into the stomach. The descending colon is part of the large intestine. Mastication occurs in the mouth, then food moves into the oropharynx and esophagus for food propulsion through the digestive tract.
A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ? a) Kidney b) Spleen c) Liver d) Gall bladder
Spleen Explanation: Percussion of the spleen begins in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness. Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage and striking it with the ulnar side of the right fist. The costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a kidney problem such as infection (pyelonephritis), renal calculi, or hydronephrosis. The gall bladder is not percussed.
The nurse understands this abdominal organ is responsible for storing red blood cells and platelets. a) Spleen b) Gallbladder c) Pancreas d) Liver
Spleen Explanation: The spleen stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The pancreas is responsible the secretion of insulin, amylase and lipase. The liver produces and secretes bile. The gallbladder stores bile.
The nurse percusses the lowest interface in the left anterior axillary line, asks the client to take a deep breath, and percusses again. The nurse is assessing for which of the following? a) Splenic percussion sign b) Kidney tenderness c) Tenderness of a nonpalpable liver d) Diaphragmatic displacement
Splenic percussion sign Explanation: A change in the percussion note from tympany to dullness on inspiration in this location suggests splenic enlargement. The given procedure is the correct technique for assessing for a positive splenic percussion sign, not kidney tenderness, liver palpation, or diaphragmatic displacement.
When inspecting the abdomen, which of the following client positions facilitates correct examination technique? a) Trendelenberg with hands over head b) Semi-Fowler's with pillows under head and knees c) Sitting with hands on hips d) Supine with arms at sides or folded across chest
Supine with arms at sides or folded across chest Explanation: A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenberg, or semi-Fowler's position.
Which of the following statements provides the most accurate guide to the assessment of the gallbladder? a) The gallbladder should be percussed and palpated prior to the liver to avoid confusing it with the larger organ. b) The margins of the gallbladder are obscured by the spleen. c) Cholecystitis and cholelithiasis are not amenable to diagnosis in the clinical setting. d) The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.
The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Explanation: Because the gallbladder is deep to the liver, it is normally not amenable to direct examination by auscultation, palpation, or percussion. This does not mean, however, that cholecystitis and cholelithiasis cannot be assessed for a thorough history. The gallbladder and the spleen are not proximate.
When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach. a) False b) True
True Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 495.
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites? a) Bilateral flank tympany b) Tympany that changes location with client position c) Dullness centrally when the client is supine d) Dullness that remains despite change in position
Tympany that changes location with client position Explanation: A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float, so dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany that changes location with client position ("shifting dullness") would support the presence of ascites. A fluid wave and edema would support this diagnosis as well. (l
The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should a) place the client in a side-lying position. b) ask the client to empty his bladder. c) ask the client to hold his breath for a few seconds. d) tell the client to raise his arms above his head.
ask the client to empty his bladder. Explanation: Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination.
The pancreas of an adult client is located a) high and deep under the diaphragm and can be palpated. b) posterior to the left midaxillary line and posterior to the stomach. c) below the diaphragm and extending below the right costal margin. d) deep in the upper abdomen and is not normally palpable.
deep in the upper abdomen and is not normally palpable. Explanation: The pancreas, located mostly behind the stomach deep in the upper abdomen, is normally not palpable. It is a long gland extending across the abdomen from the RUQ to the LUQ.
The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible a) liver disease. b) abdominal distention. c) internal bleeding. d) Cushing syndrome.
internal bleeding. Explanation: Purple discoloration at the flanks (Grey-Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the a) right upper quadrant. b) left upper quadrant. c) right lower quadrant. d) left lower quadrant.
left upper quadrant. Explanation: The spleen is located in the left upper quadrant. Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 474.
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the a) left lower quadrant. b) right lower quadrant. c) right upper quadrant. d) left upper quadrant.
left upper quadrant. Explanation: The spleen is located in the left upper quadrant. Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 474
While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible a) masses. b) cachexia. c) gallbladder disease. d) kidney trauma.
masses. Explanation: A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue.
The nurse assesses an adult male client's abdomen and observes diminished abdominal respiration. The nurse determines that the client should be further assessed for a) intestinal obstruction. b) umbilical hernia. c) liver disease. d) peritoneal irritation.
peritoneal irritation. Explanation: Diminished abdominal respiration or change to thoracic breathing in male clients may reflect peritoneal irritation.
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? a) right lower b) right upper c) left upper d) left lower
right upper Explanation: The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal.
A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of a) stomach ulcers. b) pancreatic cancer. c) abdominal tumors. d) decreased gastric motility.
stomach ulcers. Explanation: Vomiting with blood (hematemesis) is seen with esophageal varices or duodenal ulcers. Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 478.
During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should a) palpate the abdomen before auscultation. b) listen in each quadrant for 15 seconds. c) begin auscultation in the left upper quadrant. d) use the diaphragm of the stethoscope.
use the diaphragm of the stethoscope. Explanation: Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client's abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants