Chapter 23 Abdomen Q&A

19. 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. The nurse should document which of the following? A) Positive Rovsing's sign B) Psoas sign present C) Obturator sign positive D) Positive skin hypersensitivity test

A

2. When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication? A) Vitamin supplement with iron B) Nonsteroidal anti-inflammatory drug C) Antidepressant D) Hormone replacement

A

23. An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide? A) Quit smoking as soon as possible. B) Exercise for at least 30 minutes, three times per week. C) Eat several small meals a day rather than three larger meals. D) Attend screening clinics at least twice per year.

A

26. The nurse is assessing the gastrointestinal system of an 81-year-old client. What age- related change should the nurse consider when collecting and analyzing assessment data? A) The client is more vulnerable to impaired nutrition due to decreased appetite. B) The client derives less nutritional value from food because of decreased enzyme production. C) The client's liver will be significantly larger than that of a younger client. D) The client will have greater bowel motility than a younger adult.

A

30. The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment? A) Ask the client to breathe slowly and deeply. B) Perform auscultation prior to palpation. C) Explain the procedure to the client before palpating. D) Position the client sitting upright.

A

8. A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following? A) It is a normal-sized liver. B) The liver is larger than normal. C) It is a smaller-than-normal liver. D) The liver has atrophied.

A

18. A nurse is reviewing the various causes associated with abdominal distention. Which of the following should the nurse identify? Select all that apply. A) Fat B) Stool C) Gas D) Hernia E) Fibroid tumors

A, B, C, E

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

B

14. A client's bladder is found to be distended. At which location should the nurse begin palpating? A) At the umbilicus B) At the symphysis pubis C) In the right lower quadrant D) In the left lower quadrant

B

17. The nurse is assessing a client who is in liver failure and who has developed ascites. When measuring the client's abdominal girth, the nurse should place the client in which position? A) Sitting B) Standing C) Supine D) Prone

B

20. The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate? A) I'm going to examine the area where you're having pain first to get a better picture of what's going on. B) Before I get ready to examine the painful area, I will let you know in plenty of time. C) You don't need to worry about anything. I will make sure to be very gentle during the exam. D) Since you're having pain in a certain area, I won't have to do a very detailed exam there.

B

22. A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem? A) Do you feel like you're able to adequately address the stress in your life? B) Do you take painkillers like aspirin on a regular basis? C) Do you tend to eat foods that are quite high in fat? D) Are you currently taking vitamin supplements?

B

24. A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor? A) Excessive fat and sugar intake B) Overuse of laxatives C) Obesity D) Inadequate abdominal muscle tone

B

7. The nurse is percussing a client's liver and is assessing liver descent. The nurse should have the client do which of the following? A) Cough forcefully B) Hold the breath C) Breathe in and out deeply D) Perform the Valsalva maneuver

B

9. Which of the following should a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration? A) Hepatomegaly B) Splenomegaly C) Abdominal mass D) Intestinal air

B

10. While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following? A) Hernia B) Malignancy C) Infection D) Aneurysm

C

15. The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location? A) Right upper quadrant B) Left upper quadrant C) Right lower quadrant D) Left lower quadrant

C

21. 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? A) Absorbing electrolytes B) Secreting digestive enzymes C) Absorbing large amounts of water D) Secreting bile

C

28. The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen? A) Accentuated tympany B) Hyperresonance C) Tympany D) Dullness

C

29. The nurse is performing blunt percussion of a client's kidneys. For what abnormal finding is the nurse primarily assessing? A) Dullness B) Tympany C) Tenderness D) Hyperresonance

C

3. A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? A) Palpate, percuss, inspect, auscultate B) Auscultate, inspect, palpate, percuss C) Inspect, auscultate, percuss, palpate D) Percuss, inspect, auscultate, palpate

C

4. To promote relaxation of the client's abdominal muscles, which of the following would be most appropriate for the nurse to do? A) Encourage the client to hold his or her breath. B) Cover the client in a warm blanket. C) Place a pillow under both of the client's knees. D) Assure the client that painful areas will not be examined.

C

5. A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? A) Tenderness on palpation B) Diastasis recti C) Cullen's sign D) Tympany on percussion

C

1. During deep palpation of the client's abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following actions would be most appropriate? A) Refer the client for medical follow-up. B) Evaluate further for a problem with the spleen. C) Assess urinary output. D) Document the position of the liver.

D

12. During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take? A) Refer the client to an oncologist. B) Provide a dietician consult for the client. C) Counsel the client regarding hernia repair. D) Stop palpating and get medical assistance.

D

13. A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation? A) Sitting upright B) Prone C) Semi-Fowler's D) Right side-lying

D

16. The nurse demonstrates the correct technique for assessing the psoas sign by which action? A) Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing B) Tapping fingerpads over the client's abdominal wall, feeling for a floating mass C) Percussing over the client's symphysis pubis with the client supine and then sitting upright D) Flexing the client's right hip, applying downward pressure on the right thigh

D

25. The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. How should the nurse proceed with assessment? A) Review the client's blood work for low platelets and hemoglobin. B) Assess the client for signs and symptoms of fluid volume overload. C) Assess the client's nutritional status. D) Assess the client for other signs and symptoms of liver disease.

D

27. The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment? A) Repeat auscultation in four to six hours. B) Palpate the client's abdomen to stimulate bowel motility. C) Perform abdominal percussion, wait three to five minutes and then repeat auscultation. D) Listen for at least five minutes before documenting an absence of bowel sounds.

D

6. A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following? A) Normoactive B) Hyperactive C) Hypoactive D) Absent

D