ch. 23 abdomen
The nurse needs to assess the abdomen of a hospitalized client post gastrointestinal surgery. Place the following assessment steps in order as the nurse enters the client's room.
1. Perform a general survey of safety hazards. 2. Inspect the abdomen. 3. Auscultate all four quadrants. 4. Palpate for tenderness. 5. Document the findings.
The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by
Cirrhosis and nephrosis
The nurse assess for kidney tenderness at what location?
Costovertebral angle
The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain?
Dyspepsia For more chronic symptoms, dyspepsia is defined as chronic or recurrent discomfort or pain centered in the upper abdomen.
Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely?
IBS
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the
LUQ
A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement?
Measure abdominal girth 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 deep palpation of the abdomen, a client experiences right lower quadrant rebound tenderness. The nurse should conduct which additional assessments? (Select all that apply.)
Palpate for the Rovsing's sign. Assess for a Psoas sign. Assess for the Obturator sign.
A nurse is attempting to palpate the abdomen of a 6-year-old girl, but the girl is so ticklish that the nurse cannot proceed. Which of the following should the nurse do?
Place the client's hand under the nurse's hand for a few moments
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?
Place the tape measure behind the client and measure at the umbilicus
The client with a acute appendicitis has been ordered a barium enema. What should the nurse do first?
Question the order as a barium enema is contraindicated in acute appendicitis A barium enema should not be performed on a client suspected of having an acute inflammatory condition, such as appendicitis, diverticulitis, or ulcerative colitis, or who has a perforated hollow organ. The barium enema can cause an inflamed area of the bowel to rupture and death may result.
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's
RUQ
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?
Splenic percussion sign 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.
Which of the following statements provides the most accurate guide to the assessment of the gallbladder?
The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.
The abdominal contents are enclosed externally by the abdominal wall musculature—three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external
abdominal oblique.
Which of the following acute abdominal symptoms could be life threatening?
abdominal pain Severe dehydration from nausea and vomiting, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Striae, or stretch marks, usually accompany pregnancy or changes in weight and are not of themselves life threatening. Kidney stones are a disorder, not a symptom. Acute indigestion is usually not life threatening.
The client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for?
acute pancreatitis
A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action?
ask when pain began
During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document this finding?
associated manifestation
The nurse is taking the health history of a client who takes a calcium channel blocking medication for hypertension. The client reports a sensation of incomplete evacuation when having a bowel movement about three times per week. For which problem should the nurse further assess the client?
constipation
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?
crohn's disease
The pancreas of an adult client is located
deep in the upper abdomen and is not normally palpable.
Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is
difficult to localise
The nurse notes that a client's abdominal skin is pale and taut. What should the nurse suspect is causing this finding?
fluid accumulation
Which of the following people need to be vaccinated for hepatitis A and B?
food service workers
A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?
gastric ulcer
Where in the digestive tract is most of the water absorbed?
large intestine
A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse?
listen for 5 minutes
A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10-year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time?
listen with bell for vascular sounds
A nurse cares for a client with a duodenal ulcer. The nurse knows that which characteristic of pain is generally associated with the client's condition?
may awaken the client at night
You are assessing a client for acute cholecystitis. What sign would you assess for?
murphy sign A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.
A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?
murphys
When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding?
normal
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should
palpate deeply while quickly releasing pressure.
A client reports the onset of pain in the left upper quadrant of the abdomen with the ingestion of alcohol. The nurse recognizes that alteration in function of which organ is most likely to be the cause of this pain?
pancreas
To palpate the spleen of an adult client, the nurse should
place right hand below left costal margin
To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should
raise the client's right leg from the hip.
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?
referred pain
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?
spleen
Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?
spleen The spleen resides in the abdominal cavity and stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The pancreas resides in the abdominal cavity and is an endocrine gland producing several important hormones, including insulin. The gallbladder, also located in the abdominal cavity, stores bile before it is released into the small intestine. The liver, an organ also located in the abdominal cavity, has a variety of functions to include detoxification, protein synthesis, and the production of biochemical used in the digestion process.
A nurse performs light palpation of the abdomen and feels a prominent, nontender, pulsating mass above the umbilicus that measures approximately 6 cm. What is an appropriate action by the nurse?
stop palpation and call HCP
When the nurse is obtaining a health history of the urinary system, the client reports "leaking" urine when coughing or laughing. Which of the following problems is the client likely experiencing?
stress incontinence
A nurse suspects that a client has gastroesophageal reflux disease (GERD). Which risk factors must be present for the nurse to confirm this? Select all that apply.
taking multiple medications hiatal hernia body mass index greater than 30
During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should
use the diaphragm of the stethoscope 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.
A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition?
viral hepatitis
