Chapter 23 Assessing Abdomen

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

"How many times have you been pregnant?"

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. 3 Inspect the abdomen. 5 Auscultate all four quadrants. 2 Palpate for tenderness. 4 Document the findings.

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

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

Abdominal aortic aneurysm

The nurse suspects an abdominal aortic aneurysm when what is assessed? Abdominal bruit Hypertension Warm extremities Increased femoral pulses

Abdominal bruit

A nurse examines a client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of the client's abdomen? Erratic Hyperactive Absent Borborygmus

Absent

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 mechanical intestinal obstruction Mesenteric ischemia Acute cholecystitis Acute appendicitis

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? Pancreatitis Appendicitis Cholecystitis Peptic ulcer

Appendicitis

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

Appendicitis

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

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? Absent Hypoactive Erratic Borborygmus

Borborygmus

The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what? Borborygmi Bruit Friction rub Venous hum

Bruit

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? clostridium difficile infection pancreatic insufficiency sigmoid colon lesion Constipation

Constipation

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

Constipation related to decrease in fluid intake

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 Gastroesophageal reflux Pancreatitis Gastric ulcer

Crohn's disease

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

When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize? Social patterns; past medical history Family history; dietary habits Surgical history; family history Dietary habits; social patterns

Family history; dietary habits

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen? Avoid the use of pillow under the head during examination Provide privacy to the client and instruct him to relax Flex the client's legs by placing a pillow under the knees Raise the client's arms or fold them behind the head

Flex the client's legs by placing a pillow under the knees

An older adult client who is admitted to the hospital with acute confusion has urinary incontinence. The nurse can accurately document this as which type of incontinence? stress overflow urge Functional

Functional

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 Helicobacter pylori Staphylococcus aureus Escherichia coli

Helicobacter pylori

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? Acute onset of appendicitis with possible rupture Intestinal obstruction at the sigmoid colon Internal adhesions from previous surgery Peritonitis from a ruptured diverticulum

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? Malabsorption syndrome Irritable bowel syndrome Inflammatory infections Secretory infections

Irritable bowel syndrome

A client expresses pain when the left costovertebral angle is palpated. What should the nurse suspect is occurring with this client? Select all that apply. Kidney infection Renal calculi Hydronephrosis Hepatitis Cholecystitis

Kidney infection Renal calculi Hydronephrosis

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? Assess for findings of dehydration Palpate for abdominal rigidity Listen for a total of 5 minutes Document the absence of bowel sounds

Listen for a total of 5 minutes

A client reports the feeling of increased gas in the abdomen. The nurse recognizes that which organs may be difficult to percuss due an increase in air or intestinal gas? Select all that apply. Liver Stomach Spleen Gallbladder Kidney

Liver Spleen

The nurse performs the assessment technique shown. What is the nurse assessing in this client? Engorged pancreas Liver size Distended gall bladder Colon obstruction

Liver size

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

Middle of the ventral abdominal wall

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

Murphy sign

A nurse observes the abdomen of a client and notices it to be distended below the umbilicus. The nurse recognizes that this can be caused by which of these conditions? Select all that apply. Pancreatic mass Ovarian tumor Full bladder Uterine enlargement Tumor of the kidney Impacted colon

Ovarian tumor Full bladder Uterine enlargement Impacted colon

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 Drape the client's genital area when the client is not being examined Adjust the bed level Hold the nurse's hands under warm water just before the examination

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 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

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? Flush the catheter tubing with sterile normal saline. Prepare to obtain a urine specimen for culture. Encourage the client to increase PO fluid intake. Record the findings as expected for a client with an indwelling catheter.

Prepare to obtain a urine specimen for culture.

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.) Murphy sign Obfuscator sign Psoas sign Rovsing sign Cutaneous hyperesthesia

Psoas sign Rovsing sign Cutaneous hyperesthesia

The nurse correctly identifies the gallbladder is located where? RUQ RLQ LUQ LLQ

RUQ

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? Kidney Gall bladder Spleen Liver

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 Gallbladder Liver Pancreas

Spleen

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

Supine with arms at sides or folded across chest

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be? Perineal Upper abdomen Suprapubic Back

Suprapubic

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 gallbladder should be percussed and palpated prior to the liver to avoid confusing it with the larger organ. Cholecystitis and cholelithiasis are not amenable to diagnosis in the clinical setting. The margins of the gallbladder are obscured by the spleen.

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.

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

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should ask the client to empty his bladder. tell the client to raise his arms above his head. ask the client to hold his breath for a few seconds. place the client in a side-lying position.

ask the client to empty his bladder.

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

costovertebral angle

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

left lower quadrant.

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

light palpation

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible gallbladder disease. masses. kidney trauma. Cachexia.

masses

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 aortic aneurysm. paralytic ileus. gastroenteritis. fluid and electrolyte imbalances.

paralytic ileus

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

raise the client's right leg from the hip.

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

right upper quadrant.

During an assessment, the patient describes vomiting moderate amounts that "smell like poop." The nurse might suspect small bowel obstruction hypercalcemia irritable bowel syndrome gastric varices

small bowel obstruction

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. decreased gastric motility. abdominal tumors. pancreatic cancer.

stomach ulcers

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

use the diaphragm of the stethoscope.