Chapter 20 Prep U

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?

"How many times have you been pregnant?"

A student nurse is auscultating for bowel sounds on a client who returned from surgery 48 hours ago. The student tells the charge nurse that she cannot hear bowel sounds in the lower quadrants. What is the appropriate response by the charge nurse to this information?

"It takes about 3 to 5 days after surgery for the bowel sounds to return completely."

The nurse is assessing an older adult client who has lost 2.27 kg (5 lb) since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for

appetite changes.

The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area?

auscultation

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 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?

hepatitis

The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation?

identify abdominal organs

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the

left upper quadrant.

A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness?

light palpation

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?

Abdominal aortic aneurysm

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

Absorbing large amounts of water

A 26-year-old sports store manager comes to the clinic with severe right-sided abdominal pain for 12 hours. He began having a stomach ache yesterday with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 38.8° and his heart rate is 170. His bowel sounds are decreased, and he has rebound and involuntary guarding at one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain?

Acute appendicitis

Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?

Appendicitis

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what?

Appendicitis

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?

Avoid excessive alcohol intake

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

During an assessment of a client's abdomen the nurse is observed performing the action shown. What is the nurse assessing?

Bladder

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?

Borborygmus

The nurse is percussing a client's liver and is assessing liver descent. The nurse would have the client do which of the following?

Breathe deeply

The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what?

Bruit

Older adults often have trouble with swallowing. What might cause this?

Decreased saliva production

Why is the appearance of urine important to evaluate during an abdominal examination?

Dark urine may be from dehydration

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

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?

Fluid accumulation

A daycare worker presents to the office with jaundice. She denies IV drug use, blood transfusion, and travel, and has not been sexually active for the past 10 months. Which type of hepatitis is most likely?

Hepatitis A

A client presents to the emergency department with reports of new onset of abdominal pain for the past three (3) days. The client states there is also a pulling feeling on the right side. Upon examination the nurse notices a 5cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process?

Internal adhesions from previous surgery

A 21 year old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology?

Irritable bowel syndrome

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Listen for five minutes before documenting an absence of bowel sounds.

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

A patient's most recent laboratory results indicate increases in alanine aminotransferase (ALT) and aspartate aminotransferase (AST). What might the nurse suspect is wrong with this patient?

Liver disease

The nurse is assessing an adult client with right lower quadrant abdominal pain. The client has no history of prior surgeries, has no allergies, and is physically fit. Which of the following should the nurse do during the abdominal examination?

Observe the client's face for signs of discomfort

Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure?

Overflow incontinence

To promote relaxation of the client's abdominal muscles, what would be most appropriate for the nurse to do?

Place a pillow under both of the client's knees.

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

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

Positive Rovsing's sign

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant?

Spleen

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6 cm mass above the umbilicus?

Stop palpating and get medical assistance.

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?

Suprapubic

A client reports severe pain in the left lower quadrant of 3 days' duration. How should the nurse conduct palpation of the abdomen due to this history?

The left lower quadrant is palpated last

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem?

Visible peristaltic waves

True or False: Rovsing's sign is a test of referred rebound tenderness in appendicitis.

True

True or False: When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach.

True

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?

place a small pillow under the client's knees

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

right upper

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's

right upper quadrant.

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

stomach ulcers.

A nurse is assessing a client with a history of alcohol abuse. The client reports right upper quadrant pain. Which type of pain is the client experiencing?

visceral