Abdomen Project Health Assessment
During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate? a) Refer the client for medical follow-u b) Evaluate further for a problem with the spleen c) Assess urinary output d) document the position of the liver
A. Document the position of the liver
When you percuss over the liver, what sound should you hear? A. Dullness B. Tympany C. Resonance D. Hyperresonance
A. Dullness
A nurse notices that a patient has ascites, which indicates the presence of: A. Fluid B. Feces C. Flatus D. Fibroid tumors
A. Fluid
A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen? a) Absent b) hyperactive c) hypoactive d) erratic
A. absent
Name the factors believed to cause ulcerative colitis?
Acidic diet , Chronic constipation and Emotional stress.
What is a finding in an elderly client during abdominal assessment that should prompt a nurse to perform additional assessment?
An enlarged liver felt during palpation.
During an abdominal assessment, the nurse would consider which of these findings as normal? A. Presence of a bruit in the femoral area B. Tympanic percussion note in the umbilical region C. Palpable spleen between the ninth and eleventh ribs in the left mid-axillary line D. Dull percussion note in the left upper quadrant at the mid-clavicular
B. Tympanic percussion note in the umbilical region
The nurse is percussing a client's liver and is assessing liver descent. The nurse would have the client do which of the following? a) ought forcefully b) holds his or her breath c) breathe deeply d) perform the Valsalva maneuver
C. Breathe deeply
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) document the absence of bowel sounds b) assess for findings of dehydration c) listen for a total of 5 minutes d) palpate for abdominal rigidity
C. Listen for a total of five (5) minutes
What other signs and symptoms are associated with an infected appendicitis. SELECT-ALL-THAT-APPLY A. Increased red blood Cells B. Patient has the desire to be positioned in the prone position to relieve pain C. Umbilical pain that extends in the right lower quadrant D. Abdominal rebound tenderness E. Abdominal Flaccidity
C. Umbilical pain that extends in the right lower quadrant D. Abdominal rebound tenderness
In order, what are the sequence of techniques used during the abdominal assessment?
Inspection, Auscultation, Percussion, Palpation
What is the purpose of light palpation in an abdominal assessment?
To identify areas of tenderness, and muscular resistance
A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah's Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for nurse Christian who's caring for the client to: a. realize the surgeon has the right to refuse to care for the client b. advise the surgeon to arrange for an alternate cardiac surgeon c. tell the client that she can donate her own blood for the procedure d. inform the client that her decision could shorten her life
a. realize the surgeon has the right to refuse to care for the client
