Ch23: abdomen

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? Hypoactive Erratic Absent Borborygmus

Borborygmus 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 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? Bowel sounds normal. Bowel sounds hypoactive. Bowel sounds inconsistent. Bowel sounds hyperactive.

Bowel sounds normal. Normal bowel sounds consist of clicks and gurgles that occur at an estimated frequency of 5 to 34 per minute. The nurse should document that the bowel sounds are normal. Twenty bowel sounds in a minute is not hyperactive, hypoactive, or inconsistent.

When palpating a client's abdomen, the nurse notes that the liver has a firm edge. What is the likely cause of his abnormal characteristic? Cirrhosis Splenomegaly Liver failure Calcification of the liver

Cirrhosis A firm hepatic edge is indicative of cirrhosis. A firm edge does not indicate liver failure or calcification. Such an edge is associated with hepatomegaly, not splenomegaly.

A hospitalized client reports nausea, vomiting, right lower quadrant abdominal pain with cramping, and frequent watery stools with significant weight loss. The nurse should further assess the client for other signs and symptoms of which disorder? gastroesophageal reflux disease (GERD) colitis diverticulitis Crohn disease

Crohn disease Weight loss, nausea, vomiting, diarrhea (multiple watery stools throughout the day), right lower quadrant pain with cramping and lack of energy are signs and symptoms of Crohn disease. Diverticulitis is an outpouching of the large intestine that causes pain in the left lower quadrant. Colitis affects the distal colon; clients with colitis have frequent bloody stools. Gastroesophageal reflux disease (GERD) occurs when gastric contents regurgitate up into the esophagus, causing discomfort.

An older client presents with symptoms of pain on urinating. The nurse recognizes that older adults are at increased risk for urinary tract infections for which of the following reasons? Decreased activity of protective bacteria in the urinary tract Higher fat-to-lean muscle ratio Poor nutrition Inadequate hydration

Decreased activity of protective bacteria in the urinary tract Older adult clients are prone to urinary tract infections because the activity of protective bacteria in the urinary tract declines with age. It is not established that older adults have poorer hydration or nutrition than younger adults. A higher fat-to-lean muscle ratio would not affect risk for urinary tract infections.

The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location? Between the umbilicus and the symphysis pubis Midline at the umbilicus Slightly above the suprapubic area Deep epigastrium to the left of midline

Deep epigastrium to the left of midline To palpate the aorta, the nurse would palpate deeply in the epigastrium, slightly to the left of midline. The pregnant uterus may be palpated above the level of the symphysis pubis in the midline. A filled bladder may be palpated in the abdomen above the symphysis pubis.

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? Hum Rub Hollow tympanic notes Dullness

Dullness 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 auscultatory sounds.

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? Streptococcus pyogenes Escherichia coli Helicobacter pylori Staphylococcus aureus

Helicobacter pylori 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.

Where in the digestive tract is most of the water absorbed? Ileum Duodenum Large intestine Stomach

Large intestine Any food particles not absorbed by the small intestine pass into the large intestine, where a few electrolytes and water are further absorbed.

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? Increased by intake of food May awaken the client at night Relieved by drinking water Throbbing in nature

May awaken the client at night A client with duodenal ulcers would have severe pain that awakens him at night. The pain may not increase by the intake of food but may be relieved by it. The pain is unrelated to drinking water. The nature of the pain may vary and may not necessarily be throbbing.

The nurse understands that the liver does what? Secretes insulin Produces clotting factors Secretes amylase Secretes lipase

Produces clotting factors The liver produces clotting factors. The pancreas secretes insulin, amylase and lipase.

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? Localized pain Radiated pain Referred pain Chronic pain

Referred pain 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.

The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the left upper quadrant. external oblique angle. costovertebral angle. right upper quadrant.

costovertebral angle. Kidney tenderness is best assessed at the costovertebral angle.

To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's left upper quadrant. right upper quadrant. left lower quadrant. right lower quadrant.

right lower quadrant. The appendix is located in the right lower quadrant.

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. 3Auscultate all four quadrants. 5Perform a general survey of safety hazards. 4Document the findings. 2Palpate for tenderness. 1Inspect the abdomen.

5Perform a general survey of safety hazards. 1Inspect the abdomen. 3Auscultate all four quadrants. 2Palpate for tenderness. 4Document the findings. After assessing for safety hazards, the abdominal assessment proceeds in the following order: inspection, auscultation, palpation. Upon completion of the assessment, the findings should be documented.

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 "I should discontinue the iron tablets and eat foods that are high in iron." "Constipation should decrease if I take the iron tablets with milk." "I should cut down on the number of iron tablets I am taking each day." "I can decrease the constipation if I eat foods high in fiber and drink water."

"I can decrease the constipation if I eat foods high in fiber and drink water." High iron intake may lead to chronic constipation.

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what? Ascites Abdominal tumor Abdominal aortic aneurysm Inflammation

Abdominal aortic aneurysm Pulsation of the aorta may be increased and lateralized in an abdominal aortic aneurysm. Ascites is collection of fluid in the abdomen. Inflammation and tumors do not pulsate.

Which of the following acute abdominal symptoms could be life threatening? Kidney stones Indigestion Abdominal pain Striae

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.

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? Inflammation Fluid accumulation Bleeding Obstruction

Fluid accumulation 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.

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 rectal abdominis. abdominal oblique. umbilical oblique. transverse abdominis.

abdominal oblique. The abdominal contents are enclosed externally by the abdominal wall musculature, which includes three layers of muscle extending from the back, around the flanks, to the front. The outermost layer is the external abdominal oblique.

The pancreas of an adult client is located below the diaphragm and extending below the right costal margin. high and deep under the diaphragm and can be palpated. deep in the upper abdomen and is not normally palpable. posterior to the left midaxillary line and posterior to the stomach.

deep in the upper abdomen and is not normally palpable. 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.

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the left upper quadrant. left lower quadrant. right upper quadrant. right lower quadrant.

left upper quadrant. The spleen is located in the left upper quadrant.

Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is usually difficult to localize also called referred pain right or left sided more severe than parietal pain

usually difficult to localize Visceral pain occurs when hollow abdominal organs, such as the intestines, become distended or contract forcefully, or when the capsules of solid organs such as the liver and spleen are stretched. Poorly defined or localized and intermittently timed, this type of pain is often characterized as dull, aching, burning, cramping, or colicky.

A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action? Ask the client when the pain began. Obtain a 24 hour diet recall. Document a detailed health history. Ask about pertinent risk factors.

Ask the client when the pain began. If a client 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 client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause? Pancreatitis Gastroesophageal reflux Gastric ulcer Crohn's disease

Gastric ulcer 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 nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ? Gallbladder Liver Spleen Kidney

Kidney 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. Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage & striking it with the ulnar side of the right fist. Percussion of the spleen begins in the left mid-axillary line & progresses downward until the sound changes from lung resonance to splenic dullness. The gallbladder is not percussed.

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? Transverse abdominis Peritoneum Linea alba Internal abdominal oblique

Linea alba 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).

Your client 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 client? Malabsorption syndrome Lactose intolerance Crohn disease Ulcerative colitis

Malabsorption syndrome 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.

When assessing the abdomen, the nurse auscultates before percussing because: Auscultation will identify any painful regions. Percussion may alter the character of bowel sounds. Percussion and palpation may increase the frequency of bruits. Percussion may alter the frequency of bowel sounds.

Percussion may alter the frequency of bowel sounds. Auscultation should precede percussion and palpation, because they may alter the frequency of the client's bowel sounds.

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? Left lower quadrant Right lower quadrant Right upper quadrant Left upper quadrant

Right upper quadrant The liver is the largest solid organ in the body. It is located below the diaphragm in the right upper quadrant of the abdomen.

The nurse is assessing a client's abdomen as shown. Which technique is the nurse using? Hooking Light palpation Percussion Two-handed deep palpation

Two-handed deep palpation The use of two hand to identify abdominal organs is the technique of two-handed deep palpation. Hooking is a technique where the fingers are curled around an area of the abdomen in order to trap or hold an organ. Percussion uses one hand placed over the region while a finger of the other hand is tapped. Light palpation is performed with one hand.

A nurse palpates an abdominal mass in the client's right lower quadrant. The nurse suspects that this mass could be associated with which of the following organs? Select all that apply. bladder ascending colon right kidney transverse colon appendix

ascending colon appendix The organs that can be palpated through the right lower quadrant of the abdomen include the appendix and the ascending colon. The right kidney is accessible through the right upper quadrant. The transverse colon is accessible through the right and left upper quadrants of the abdomen. The bladder can be palpated in the lower abdominal midline.

The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation? complete a surface evaluation identify abdominal organs detect abdominal tenderness discern muscular resistance

identify abdominal organs Deep palpation is performed to identify abdominal organs. Light palpation is completed to discern muscular resistance, detect abdominal tenderness, and complete a surface evaluation.

While auscultating rushes of high-pitched bowel sounds a client complains of abdominal pain. What should the nurse suspect is occurring with this client? diarrhea peritonitis ileus intestinal obstruction

intestinal obstruction Rushes of high-pitched sounds coinciding with an abdominal cramp indicate intestinal obstruction. Bowel sounds are increased in diarrhea. Bowel sounds may be decreased and then absent in ileus and peritonitis.

While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tinkling sounds throughout the distended abdomen. The nurse should refer the client to a health care provider for possible inflamed appendix. intestinal obstruction. cirrhosis of the liver. gastroenteritis.

intestinal obstruction. Obstruction often presents with high-pitched tinkling sounds above the obstruction, in combination with distended abdomen; abdominal cramping is often present as well. Gastroenteritis may present with hyperactive bowel sounds that include tinkling, rushing, and high-pitched sounds and diarrhea is typical, but a distended abdomen is not typical. Cirrhosis of the liver may present with venous hum.

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? alcohol hepatitis intrahepatic jaundice toxic liver damage viral hepatitis

viral hepatitis Travel to or consuming food meals in an area of poor sanitation can pose a risk for contracting viral hepatitis. This information paired with the client's report of having gray colored stools increases the likelihood of obstructive jaundice related viral hepatitis. Toxic liver damage can result from side effects of certain medications, inhaling or consuming industrial solvents, or exposure to environmental toxins. Alcohol hepatitis is secondary to alcohol abuse. Intrahepatic jaundice arises from damage to the hepatocytes or intrahepatic bile ducts.

A 22-year-old law student comes to the office complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs, but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank around 14 drinks. Examination shows a young man appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending. What etiology of abdominal pain is most likely causing his symptoms? Biliary colic Acute pancreatitis Peptic ulcer disease Acute cholecystitis

Acute pancreatitis Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates into the back. There is often a history of long-standing gallbladder disease or recent alcohol ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump inhibitors can also cause pancreatitis in people without these other risk factors. Treatment includes hydration, pain management, and bowel rest.

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 Biliary colic Acute cholecystitis Acute diverticulitis

Acute pancreatitis With acute pancreatitis, epigastric pain may radiate to the back or other parts of the abdomen; it may be poorly localized.

Which finding obtained during the abdominal assessment in an older adult client should prompt the nurse to perform an additional assessment to determine the cause? Tympany percussed over the stomach An enlarged liver felt during palpation Negative fluid wave test Report of a decrease in appetite

An enlarged liver felt during palpation The liver normally decreases in size after age 50 years. An enlarged liver needs further assessment. Appetite decreases with age due to altered metabolism, decreased taste sensation, decreased mobility, and possibly depression. Tympany is a normal finding over the stomach. The fluid wave test should be negative unless fluid (ascites) is present in the abdomen.

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? Inflammation of the gallbladder Appendicitis Liver engorgement Kidney pain

Appendicitis RLQ pain constitutes a positive obturator sign, suggesting an inflamed appendix or peritoneal inflammation. Kidney tenderness is assessed posteriorly. The Blumberg assesses for rebound tenderness and the Murphy test is for inflammation of the gallbladder.

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? Kidney pain Inflammation of the gallbladder Appendicitis Liver engorgement

Appendicitis RLQ pain constitutes a positive obturator sign, suggesting an inflamed appendix or peritoneal inflammation. Kidney tenderness is assessed posteriorly. The Blumberg assesses for rebound tenderness and the Murphy test is for inflammation of the gallbladder.

The nurse would assess for positive Blumberg sign how? Having the client breathe deeply Applying blunt pressure that the midclavicular line (MCL) Applying and releasing pressure to the abdomen Applying blunt pressure at the costovertebral angle (CVA)

Applying and releasing pressure to the abdomen Pain that occurs after applying and releasing pressure to the abdomen would be a positive Blumberg sign. Murphy sign occurs when the client holds his breath and there is pain. Blunt pressure at the CVA assesses for kidney pain. Liver span test occurs at the MCL.

A client is admitted with abdominal pain. The nurse conducts a focused specialty assessment on the client. Which of the following are specialty assessment technique(s) that the nurse will include in this assessment? Select all that apply. Assess for psoas sign. Perform a deep palpation of the spleen and other organs. Auscultate bowel sounds in all quadrants. Percuss the size of the liver. Observe for aortic pulsations.

Assess for psoas sign. Perform a deep palpation of the spleen and other organs. Percuss the size of the liver. A focused specialty abdominal assessment includes techniques in addition to the basic assessment; specialty techniques include assessing for psoas sign, percussing the size of organs such as the liver, and deep palpation. Inspection (symmetry, aortic pulsations, etc.), auscultation (bowel sounds in all four quadrants), light palpation, and percussion of tones are all part of the basic assessment only.

The nurse is assessing a client in the emergency department. The client was involved in a motor vehicle accident and is experiencing left upper abdominal pain. The nurse should intervene when another health care provider does which of the following? Orders a spiral computerized tomography (CT) scan Places a cervical collar on the client Attempts to palpate the spleen Uses the left arm for phlebotomy

Attempts to palpate the spleen If trauma to the spleen is suspected, the spleen should not be palpated. Palpation could cause the spleen to rupture and the nurse should intervene to prevent this from happening. The nurse would expect for the client to be placed in a cervical collar as the client was in a motor vehicle accident. The cervical collar should remain in place until the neck and spine are deemed stable. A spiral computerized tomography (CT) scan is expected to be ordered to rapidly help identify injuries sustained during the accident. The nurse should also expected blood to be drawn quickly from any site available to monitor the hemoglobin and hematocrit, as there is a need to check for internal bleeding.

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? Constipation related to decrease in fluid intake Ineffective Nutrition: Less Than Body Requirements Risk for Fluid Volume Deficit Ineffective Health Maintenance

Constipation related to decrease in fluid intake 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.

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 Dysphagia Discomfort Odynophagia

Dyspepsia For more chronic symptoms, dyspepsia is defined as chronic or recurrent discomfort or pain centered in the upper abdomen.

Mr. Kruger, 84 years old, presents with a smooth lower abdominal mass in the midline, which is minimally tender. There is dullness to percussion up to 6 cm above the symphysis pubis. What does this most likely represent? Hernia Tumor in the abdominal wall Sigmoid mass Enlarged bladder

Enlarged bladder It is possible that this represents a sigmoid colon mass, but this is less likely than an enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently cause partial urinary obstruction with bladder enlargement. If the mass resolves with catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A hernia would most likely not be dull to percussion. Midline abdominal wall tumors of this size would be unusual but could be discerned by having the client tense his abdominal muscles.

The nurse notes that a client's abdominal skin is pale and taut. What should the nurse suspect is causing this finding? Fluid accumulating in the abdominal cavity Inflammation of the liver Bleeding within the abdominal wall Obstruction of the inferior vena cava

Fluid accumulating in the abdominal cavity Pale taut skin may be seen with ascites which is significant abdominal swelling that indicates fluid accumulation in the abdominal cavity. Jaundice would be present if the liver is inflamed. Purple discoloration at the flank areas indicates bleeding within the abdominal wall. Dilated veins may be seen with obstruction of the inferior vena cava.

Which of the following people need to be vaccinated for hepatitis A and B? Animal care workers Food-service workers Office personnel Truck drivers

Food-service workers 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.

The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates? Inflammation of the gallbladder Kidney pain Peritonitis Appendicitis

Inflammation of the gallbladder Pain with breathing while assessing Murphy sign is an indication of inflammation of the gallbladder. Peritonitis is assessed for rebound tenderness, indicated by Blumberg sign (a sharp, stabbing pain as the examiner releases pressure from the abdomen). Kidney pain is assessed by performing blunt percussion at the costovertebral angles (CVA). Appendicitis is assessed with the iliopsoas muscle test.

A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process? Intestinal obstruction at the sigmoid colon Internal adhesions from previous surgery Acute onset of appendicitis with possible rupture Peritonitis from a ruptured diverticulum

Internal adhesions from previous surgery The key to this question is the presence of the scar. The scar in the right lower quadrant should alert the nurse to the possibility of internal adhesions, which account for the pulling feeling the client reports. An intestinal obstruction would not produce a pulling feeling, but the client most likely would report nausea and vomiting. With a right lower quadrant scar, the appendix may already be removed. Acute appendicitis would also present with fever, nausea, and vomiting. Peritonitis would cause a rigid abdomen with generalized severe abdominal pain and fever.

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? Irritable bowel syndrome Colon cancer Inflammatory bowel disease Cholecystitis

Irritable bowel syndrome Although colon cancer should be a consideration, these symptoms are intermittent and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely, especially given that she is a young woman. This very common condition can be triggered by certain foods and stress.

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? Observe for evidence of increased abdominal girth Obtain a complete set of vital signs and pain assessment Listen with the bell of the stethoscope for vascular sounds Inspect the abdomen for color, shape, and symmetry

Listen with the bell of the stethoscope for vascular sounds A client with a history of hypertension is at risk for bruits over any of the vascular areas on the abdomen such as renal artery, iliac artery, or femoral artery. The bell of the stethoscope is used for this assessment because bruits are low-pitched, murmur-like sounds. Inspection of the abdomen should be performed before auscultation. Vital signs are part of the general survey and are usually the first hands-on assessment of a client. Measuring abdominal girth is done if the nurse observes a distended abdomen or there are other signs of fluid retention within the abdomen.

The nurse is palpating in the right upper abdominal quadrant and feels and enlarged area. The nurse recognizes that she is most likely feeling what organ? Liver Gallbladder Pancreas Kidneys

Liver The liver is located in the right upper quadrant. The gallbladder and kidney are not palpable. The pancreas is located in the left upper quadrant.

A nurse receives an order to measure the abdominal girth daily on a client admitted with ascites. How should the nurse best implement this order? Have the client lying down in the bed with the head of bed slightly elevated Elevate the head of bed to concentrate the fluid in one area of the abdomen Measure at the same time each day, ideally in the morning after voiding Any time of day is acceptable when using the umbilicus as a starting point

Measure at the same time each day, ideally in the morning after voiding The umbilicus should be used as the starting point for measuring abdominal girth, especially when ascites is present. Measure the girth at the same time each day, ideally after the client voids in the morning. The ideal position is for the client to stand. If the client cannot stand, the supine position is acceptable. The head of bed should be flat unless the client has difficulty breathing.

Where is the linea alba located? Lower edge of the costal margin Anterior-superior iliac spine of the iliac bones Middle of the ventral abdominal wall Xiphoid process of the sternum

Middle of the ventral abdominal wall A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenburg, or semi-Fowler's position.

You are assessing a client for acute cholecystitis. What sign would you assess for? Cutaneous hyperesthesia Psoas sign Murphy sign Obstipation sign

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.

During the abdominal examination, a nurse supports the client's right knee and ankle. The nurse flexes the client's hip and rotates the leg externally and internally. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign? Obturator Murphy's Rovsing's Psoas

Obturator The test indicates a positive obturator sign, which is performed to assess for appendicitis. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. 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. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.

How should the nurse perform blunt percussion over the liver? 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 radial side of right fist Place left hand on right lower rib cage, strike it with ulnar side of right fist 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 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.

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? Inform the client that the pen mark on the abdomen should not be washed off Ensure that the client has had a full meal before measuring the abdomen Ask the client to be seated and relaxed when taking the measurement Place the tape measure behind the client and measure at the umbilicus

Place the tape measure behind the client and measure at the umbilicus The nurse should place the tape measure behind the client and measure at the umbilicus. The umbilicus should be the starting point when measuring the abdomen especially when distention is apparent. Abdominal measurement is generally taken in the morning after voiding, not after the client has had a full meal. The ideal position to measure the abdomen is standing not sitting. The nurse informs the client that the pen mark on the abdomen should not be washed out only if the client is being monitored on a regular basis to determine progress of treatment for abdominal distention.

The nurse assesses a client's indwelling urinary catheter bag and observes cloudy urine. The client also complains of lower back pain. What is the nurse's best action? Record the findings as expected for a client with an indwelling catheter. Encourage the client to increase PO fluid intake. Flush the catheter tubing with sterile normal saline. Prepare to obtain a urine specimen for culture.

Prepare to obtain a urine specimen for culture. The client is exhibiting symptoms of a catheter associated urinary tract infection. The nurse should notify the healthcare provider and prepare to collect a urine specimen for culture. Increased fluid intake can decrease complications of a UTI; however, a UTI must be treated with antibiotics as well. Flushing the tubing with saline involves disrupting the sterility of the line and is not routinely performed when suspecting a UTI.

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 Liver Gall bladder Kidney

Spleen 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 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 Diaphragmatic displacement Tenderness of a nonpalpable liver Kidney tenderness

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.

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? Auscultate over the same area for the presence of a bruit Use percussion to determine the solidity of the structure Assist the client to the bathroom to empty the bladder Stop the palpation and notify the health care provider

Stop the palpation and notify the health care provider A pulsating abdominal mass may indicate the presence of an abdominal aortic aneurysm. An aneurysm is an area within a vessel where the wall of the vessel becomes weak, engorged with blood, and may rupture. The nurse should stop palpating immediately and notify the health care provider. This client may need to go to surgery for repair of the aneurysm. All other options are not safe or indicated for this client at this time.

The nurse explains to the client the main function of the stomach is to do what? Select all that apply. Absorb nutrients Absorb salt and water Store food Churn food Digest food

Store food Churn food Digest food The stomach's main function is to churn, store and digest food. The small intestine absorbs nutrients and the large intestine absorbs salt and water.

When inspecting the abdomen, which of the following client positions facilitates correct examination technique? Trendelenburg with hands over head Semi-Fowler's with pillows under head and knees Supine with arms at sides or folded across chest Sitting with hands on hips

Supine with arms at sides or folded across chest A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenburg, or semi-Fowler's position.

The nurse is assessing the abdomen of a client. While percussing the abdomen, what normal sound does the nurse expect to hear? Dullness Friction rub Tympany Hollow sound

Tympany Generalized tympany predominates over the abdomen because of air in the stomach and intestines. An enlarged area of dullness would be heard over an enlarged liver or spleen. A friction rub heard over the lower right costal area is associated with hepatic abscess or metastases. A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction, abscess, infection, or tumor. A hollow sound would not be expected at the normal spleen.

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? onset associated manifestations characteristic symptoms relieving factors

associated manifestations The nurse should document this finding in the associated manifestations section because this is a report on the experience of other symptoms associated with abdominal pain. In relieving factors, the nurse explores factors that aggravate or relieve the pain. In characteristic symptoms, the nurse should ask the client to describe the pain in his or her own words. Onset refers to when the abdominal pain started.

The sigmoid colon is located in this area of the abdomen: the left lower quadrant. right upper quadrant. right lower quadrant. left upper quadrant.

left lower quadrant. The left lower quadrant (LLQ) contains the left kidney (lower pole), left ovary and tube, left ureter, left spermatic cord, and descending and sigmoid colon.

The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should palpate lightly while slowly releasing pressure. palpate deeply while quickly releasing pressure. perform this abdominal assessment first. ask the client to assume a side-lying position.

palpate deeply while quickly releasing pressure. If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen away from the painful or tender area. Then suddenly release pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred.

The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible fluid and electrolyte imbalances. paralytic ileus. aortic aneurysm. gastroenteritis.

paralytic ileus. Absent bowel sounds may be associated with peritonitis or paralytic ileus.

A nurse is performing an admission assessment on a new client. The client reports black tarry stools and abdominal pain immediately after eating. What condition would the nurse suspect? indigestion constipation Crohn disease peptic ulcer

peptic ulcer Peptic ulcer presents with abdominal pain immediately after eating (gastric ulcer) and possibly black tarry stools if bleeding is occurring. Signs and symptoms of Crohn disease include weight loss and malnutrition. Indigestion, also referred to as GERD, presents with signs and symptoms of hyperacidity after eating large meals. Abdominal pain immediately after eating and black tarry stools are not signs and symptoms of constipation.

A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment? assist to a sitting position with the legs dangling remove a pillow from behind the client's head raise the head of the bed to a 30-degree angle place a small pillow under the client's knees

place a small pillow under the client's knees A small pillow placed under the knees relaxes the abdominal musculature. The abdominal assessment should not be performed with the head of the bed raised to a 30-degree angle or sitting with the legs dangling. Removing a pillow from behind the client's head will make the abdominal muscles more tense.

To palpate the spleen of an adult client, the nurse should place the right hand below the left costal margin. ask the client to remain in a supine position. ask the client to exhale deeply. point the fingers of the left hand downward.

place the right hand below the left costal margin. To palpate the spleen stand at the client's right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the client's head. Ask the client to inhale and press inward and upward as you provide support with your other hand.

To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should palpate at the lower right quadrant. rotate the client's knee internally. raise the client's right leg from the hip. support the client's right knee and ankle.

raise the client's right leg from the hip. Assess for psoas sign by asking the client to lie on the left side. Hyperextend the right leg of the client.

The colon originates in this abdominal area: the left lower quadrant. left upper quadrant. right lower quadrant. right upper quadrant.

right lower quadrant. The colon, or large intestine, has a wider diameter than the small intestine (approximately 6.0 cm) and is approximately 1.4 m long. It originates in the RLQ, where it attaches to the small intestine at the ileocecal valve.

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? left upper left lower right lower right upper

right upper 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.

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? left upper left lower right upper right lower

right upper 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 decreased gastric motility. pancreatic cancer. abdominal tumors. stomach ulcers.

stomach ulcers. Vomiting with blood (hematemesis) is seen with esophageal varices or duodenal ulcers.

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. passing excess flatus taking multiple medications body mass index greater than 30 hiatal hernia alcohol consumption

taking multiple medications body mass index greater than 30 hiatal hernia Risk factors for gastroesophageal reflux disease (GERD) include obesity, side effects of various medications, and a hiatal hernia. Alcohol intake is not a risk factor for GERD but can aggravate heartburn, a rising pain that burns or causes discomfort weekly or more often. Passing excess flatus is commonly associated with aerophagia, lactase deficiency, or irritable bowel syndrome.

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should listen in each quadrant for 15 seconds. use the diaphragm of the stethoscope. begin auscultation in the left upper quadrant. palpate the abdomen before auscultation.

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 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 regard to this finding? "Have you noticed any color change to the skin?" "Do you have high blood pressure?" "Are you experiencing any abdominal pain?" "Have you been pregnant?"

"Have you been pregnant?" 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.