Abdominal Assessment

Based on the client's assessment, what condition would the nurse suspect? a) appendicitis b) liver failure c) cholecystitis d) ureteral colic

cholecystitis

The nurse is documenting the client's vomitus. Which documentation should be included in the client's medical record? (select all that apply.) a) client vomited green with undigested food particles b) vomit without odor c) vomit is soft in consistency d) approximately 250 mL of vomit was noted e) client vomited x 1 lasting approximately 2 minutes

client vomited green with undigested food particles, vomit without odor, approximately 250 mL of vomit was noted, client vomited x 1 lasting approximately 2 minutes

The nurse prepares the client for the physical assessment of the abdomen. What actions should the nurse take prior to initiating the assessment? (Select all that apply.) a) encourage the client to empty her bladder b) place a pillow under the client's knees c) inquire where the client is experiencing pain d) instruct the client to place her hands over her head e) discuss the sequence of steps performed during the abdominal assessment

encourage the client to empty her bladder, place a pillow under the client's knees, inquire where the client is experiencing pain, discuss the sequence of steps performed during the abdominal assessment

Which assessment take priority while the nurse provides oral care? a) assess for presence of dentures b) observes the condition of the mucus membranes c) evaluate the color of the gums d) check for the presence of cavities

observes the condition of the mucus membranes

The nurse is assessing for costa-vertebral angle (CVA) tenderness. Which statements best describe this percussion assessment? (Select all that apply.) a) it is normal for a client to feel pain with this percussion assessment b) percussion is completed over the 12th rib in the back bilaterally c) place one hand over the flan area and hit the hand with the ulnar side of the fist d) client will need to take a deep breath prior to completion of the percussion technique e) technique is used to assess for inflammation of the kidney

percussion is completed over the 12th rib in the back bilaterally, place on hand over the flank area and hit the hand with the ulnar side of the fist, technique is used to assess for inflammation of the kidney

When continuing to assess the abdominal area the nurse hears a swishing sound. In what area would this sound be hear? a) femoral artery b) epigastric area c) umbilical area d)right quadrants

femoral artery

Thirty minutes later, the nurse returns to assess the client's response to the medication. Which findings provide the best data about the effectiveness of the medication? (Select all that apply.) a) the client's vital signs are within normal limits b) the client is holding a pillow over her abdomen c) the client's facial expression is cam and relaxed d) the client states a lessening of her pain e) the spouse reports that the client looks liker her pain has improved

the client's vital signs are within normal limits the client's facial expression is calm and relaxed the client states a lessening of her pain

The nurse assesses the patient's vomitus. What finding would the nurse be the most concerned about? a) green vomit with particles of food b) thick dark brown vomit c) white foamy vomit d) yellow clear vomit

thick dark brown vomit

What action should the nurse take? a) use the client's own hand to assist with palpation b) switch to using the heel of the hand to palpate c) obtain an order for a muscle relaxant d) stop any further palpation immediately

use the client's own hand to assist with palpation

What additional focused interview questions will be important for the nurse to ask the client? a) do you have a history of any abdominal conditions or surgeries b) have you experience any weight gain or weight loss c) are you have any difficulty with urination d) are you experiencing any shortness of breath? e) do you have any difficulty swallowing your foods

do you have a history of any abdominal conditions or surgeries, have you experienced any weight gain or weight loss

What action should the nurse take in response to this finding? a) stop the assessment and notify the healthcare provider (HCP) immediately of the assessment finding b) take the client's blood pressure and heart rate after the assessment c) call another nurse to verify the finding d) document this normal finding on the client's assessment record

document this finding on the client's assessment record

What further assessment technique would the nurse consider to confirm a problem with the gallbladder? a) Murphy's sign b) illiopsoas test c) obturator test d) the Alvarado score

Murphy's sign

The nurse is completing an inspection of the abdomen. Which findings would cue the nurse of the need for action? a) the presence of striae on the right and left lower quadrants b) a protuberant shaped abdomen c) a midline, inverted umbilicus d) a large amount of pigmented nevi scattered across the abdomen e) marked visible peristalsis

a protuberant shaped abdomen, marked visible peristalsis

In response to the client's statement that she is in a lot of pain, what action should the nurse take first? a) explain to the client that post-operative pain is normal b) ask the client to describe her pain location intensity c) ask the client if she has passed has since surgery d) assess the client's heart rate and blood pressure

ask the client to describe her pain location and intensity

What questions should the nurse ask next? (Select all that apply.) a) can you identify which spicy foods cause a problem? b) how often do you eat spicy foods? c) what happens when you eat spicy foods? d) does anyone in your family have problems with spicy food? e) why do you think spicy foods are a problem?

can you identify which spicy foods cause a problem, what happens when you eat spicy foods

What action should the nurse take next? a) move to the right upper quadrant (RUQ) to hear the sounds more distinctly. b) continue to osculate for bowel sounds in the right lower quadrant c) change to the bell of the stethoscope to listen d) listen for 5 minute before documenting the activity of the bowel sounds

continue to auscultate for bowel sounds in the right lower quadrant

For the nurse to learn about the client's bowel patterns, which questions are most important to ask the client? (Select all that apply.) a) have you had any recent onset of heartburn? b) do you take any prescription or over-the-counter medication c) have you had any changes in your bowel movements? d) what is the color and consistency of your bowel movements? e) how often do you have a bowel movement?

do you take any prescription or over-the-counter medication, have you had any changes in your bowel movements?, what is the color and consistency of your bowel movements, how often do you have a bowel movement

To ensure the most accurate assessment of the abdomen, what actions should the nurse take? (place in order from first action through last action.) palpation auscultation percussion inspection

inspection, auscultation, percussion, palpation

The nurse's goal in palpating the client's abdomen is to screen for any masses or tenderness. To achieve this goal, what action should the nurse take first? A. deeply palpate each abdominal organ. B. Carefully palpate areas of tenderness. C. lightly palpate the abdominal surface. D. Gently palpate the edges of the liver

lightly palpate the abdominal surface

What is the most appropriate follow up action the nurse should implement? (Select all that apply) a) note this location as the border of the liver b) ask the client if she is constipated c) document the presence of splenic dullness c) document the finding as normal d) make a note to notify the HCP of the findings

note this location as the border of the liver, document the finding as normal

After observing the presence of rebound tenderness, the nurse notes the onset of involuntary rigidity of the client's abdomen. Which action should the nurse implement? a) notify the HCP of the findings b) assist the client to a semi-Fowler's position c) administer a pain medication d) place a warm moist pack on the client's abdomen

notify the HCP of the findings

To learn about the intensity of the client's pain, what pain scale is most appropriate to use to assess the client's pain? a) FLACC behavioral pain scale b) numeric pain scale c) faces pain scale d) non-verbal cues

numeric pain scale

A dull sound is heard when the nurse percusses over the suprapubic area. What action should the nurse take in response to this finding? a) reposition the client to her right side b) observe the area for bladder distention c) determine if the client feels bloated or gaseous d) assist the client to a sitting position immediately

observe the area for bladder distention

Which assessment should the nurse complete first? a) check the pulse b) listen to bowel sounds c) observe the color of the emesis d) obtain a STAT blood pressure

observe the color of the emesis

What statements from the clients focused interview correlate to the abnormal inspection findings? (Select all that apply.) a) daily bowel movements b) past surgical history of an appendectomy c) nausea and vomiting d) food intolerance to spicy foods e) hang in body mass index (BMI).

past surgical history of an appendectomy, change in body mass index (BMI)

When completing the pain assessment, how should the nurse assess for rebound tenderness? a) position the client on her right side b) lightly palpate over the painful area c) ask the client to describe the pain d) push down on the left side of the abdomen

push down on the left side of the abdomen

Determine the correct sequence of auscultation of the client's abdomen. (place in order from first to last.) right lower quadrant right upper quadrant left upper quadrant left lower quadrant

right lower quadrant, left lower quadrant, left upper quadrant, right upper quadrant