Chapter 23: Assessing 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. 1Palpate for tenderness. 2Inspect the abdomen. 3Auscultate all four quadrants. 4Document the findings. 5Perform a general survey of safety hazards.
5Perform a general survey of safety hazards. 2Inspect the abdomen. 3Auscultate all four quadrants. 1Palpate for tenderness. 4Document the findings. Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 508.
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? A. Absent B. Hyperactive C. Borborygmus D. Erratic
A. Absent xplanation: 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." Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Physical Assessment, p. 513.
An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What medical diagnosis is associated with the assessment finding? A. Appendicitis B. Enlarged spleen C. Liver disease D. Gastroenteritis
A. Appendicitis Explanation: Rovsing's sign is an indicator of appendicitis. It is not a sign of gastroenteritis, liver disease, or an enlarged spleen. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 526.
A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action? A. Ask the client when the pain began. B. Document a detailed health history. C. Ask about pertinent risk factors. D. Obtain a 24 hour diet recall.
A. Ask the client when the pain began. Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 501.
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? A. Attempts to palpate the spleen B. Orders a spiral computerized tomography (CT) scan C. Uses the left arm for phlebotomy D. Places a cervical collar on the client
A. Attempts to palpate the spleen Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen.
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? A. Bowel sounds normal. B. Bowel sounds inconsistent. C. Bowel sounds hypoactive. D. Bowel sounds hyperactive.
A. Bowel sounds normal. Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 512.
The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what? A. Bruit B. Borborygmi C. Friction rub D. Venous hum
A. Bruit Explanation: Bruits are swishing sound that indicate turbulent blood flow. Borborygmi is increased bowel sounds. A venous hum is a soft-pitched humming sound associated with partial obstruction of an artery and reduced blood flow to the organ. Friction rubs are a grating sounds with inspiration. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 513.
The nurse is preparing to assess the size of the aorta. The nurse would palpate at which location? A. Deep epigastrium to the left of midline B. Slightly above the suprapubic area C. Midline at the umbilicus D. Between the umbilicus and the symphysis pubis
A. Deep epigastrium to the left of midline Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 512.
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? A. Internal adhesions from previous surgery B. Peritonitis from a ruptured diverticulum C. Intestinal obstruction at the sigmoid colon D. Acute onset of appendicitis with possible rupture
A. Internal adhesions from previous surgery Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Physical Assessment, p. 510.
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? A. Irritable bowel syndrome B. Inflammatory infections C. Secretory infections D. Malabsorption syndrome
A. Irritable bowel syndrome Explanation: Irritable bowel syndrome will cause loose bowel movements with cramps, but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely found in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse as well as certain foods. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, ANALYZING DATA TO MAKE INFORMED CLINICAL JUDGMENTS, p. 527.
When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant? A. Right kidney, ascending colon, and liver B. Right kidney, transverse colon, and inguinal ligament C. Right ovary, descending colon, and spleen D. Right ovary, pancreas, and sigmoid colon
A. Right kidney, ascending colon, and liver Explanation: The pole of the right kidney, the ascending colon, and the liver are all present in the RUQ. The pancreas, descending colon, sigmoid colon, spleen, and inguinal ligament are not. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Abdominal Wall Muscles, p. 498.
The nurse is admitting a client who is in hypertensive crisis. The doctor's notes indicate that bruits that are both systolic and diastolic have been noted and renal artery stenosis is suspected as the cause of the hypertension. Where would the nurse auscultate the client's abdomen to hear these bruits? (Select all that apply.) A. Right upper quadrant B. Epigastrium C. Iliac arteries D. Costovertebral angles E. Femoral arteries
A. Right upper quadrant B. Epigastrium D. Costovertebral angles Explanation: If the client has high blood pressure, listen in the epigastrium and in each upper quadrant for bruits. Later in the examination, when the client sits up, listen also in the costovertebral angles. A bruit in one of these areas that has both systolic and diastolic components strongly suggests renal artery stenosis as the cause of hypertension. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, pp. 517-519.
When inspecting the abdomen, which of the following client positions facilitates correct examination technique? A. Supine with arms at sides or folded across chest B. Semi-Fowler's with pillows under head and knees C. Trendelenburg with hands over head D. Sitting with hands on hips
A. Supine with arms at sides or folded across chest Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 508.
Which of the following statements provides the most accurate guide to the assessment of the gallbladder? A. The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. B. The gallbladder should be percussed and palpated prior to the liver to avoid confusing it with the larger organ. C. Cholecystitis and cholelithiasis are not amenable to diagnosis in the clinical setting. D. The margins of the gallbladder are obscured by the spleen.
A. The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Explanation: Because the gallbladder is deep to the liver, it is normally not amenable to direct examination by auscultation, palpation, or percussion. This does not mean, however, that cholecystitis and cholelithiasis cannot be assessed for a thorough history. The gallbladder and the spleen are not proximate. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Internal Anatomy, p. 499.
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? A. The left lower quadrant is palpated last B. Encourage the client to relax to minimize pain C. This area should be avoided completely D. Medicate for pain before beginning the assessment
A. The left lower quadrant is palpated last Explanation: The nurse should avoid touching tender or painful areas until last and reassure the client. The area needs to be assessed for the presence of abnormal findings and should not be avoided. Medicating before palpating may obscure the findings. The client may not be able to relax just by the power of suggestion. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Abdominal Wall Muscles, p. 498.
While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen? A. To identify bowel sounds B. To identify abdominal tenderness C. To identify the distribution of gas in the abdomen D. To identify the edges of abdominal organs
A. To identify bowel sounds Explanation: Auscultation is used to identify bowel sounds when conducting the physical examination of the gastrointestinal system. Deep palpation is used to identify the edges of the liver, kidney and other abdominal masses. Light palpation is applied to identify abdominal tenderness along with muscular resistance and some superficial organs and masses. Percussion is used to identify the amount and distribution of gas in the abdomen. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 512.
A student nurse is performing a focused abdominal assessment of a hospitalized client. The nursing instructor determines proper assessment technique when the nursing student performs the assessment in what order? Place the steps in the correct order. A. inspection B. auscultation C. percussion and palpation
A. inspection B. auscultation C. percussion and palpation Explanation: For an accurate assessment of the abdomen, the nurse must inspect first, then auscultate, percuss, and palpate. The abdominal assessment is completed in this order so as to not disrupt the patterns of the bowel sounds, which may provide incorrect information to the health care provider. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 508.
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 A. masses. B. gallbladder disease. C. cachexia. D. kidney trauma.
A. masses. Explanation: A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 511.
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? A. "Do you have high blood pressure?" B. "Have you been pregnant?" C. "Are you experiencing any abdominal pain?" D. "Have you noticed any color change to the skin?"
B. "Have you been pregnant?" Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Physical Assessment, p. 510.
The nurse notes that a client experiencing right lower quadrant abdominal pain when the hip and knee are flexed, and the leg is rotated internally and externally. What should the nurse suspect is occurring with this client? A. Inflamed gall bladder B. Appendicitis C. Liver inflammation D. Peritoneal irritation
B. Appendicitis Explanation: The client is demonstrating a positive obturator sign that causes pain in the right lower abdominal quadrant when the hip and knees are flexed and the leg is rotated internally and externally. Rebound tenderness occurs with peritoneal irritation. There is no specific sign for liver inflammation. Pain that occurs when pressure is applied under the liver border at the right costal margin indicates an inflamed gall bladder. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Abdominal Wall Muscles, p. 498.
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? A. Pancreas B. Liver C. Gallbladder D. Kidneys
B. Liver Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Internal Anatomy, p. 499.
The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible A. liver disease. B. internal bleeding. C. abdominal distention. D. Cushing syndrome.
B. internal bleeding. Explanation: Purple discoloration at the flanks (Grey-Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 506.
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? A. remove a pillow from behind the client's head B. place a small pillow under the client's knees C. raise the head of the bed to a 30-degree angle D. assist to a sitting position with the legs dangling
B. place a small pillow under the client's knees Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 526.
To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's A. left upper quadrant. B. right lower quadrant. C. right upper quadrant. D. left lower quadrant.
B. right lower quadrant. Explanation: The appendix is located in the right lower quadrant. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, STRUCTURE AND FUNCTION, p. 498.
A nurse inspects a client's abdomen and notices that a bulge is present in the right lower quadrant. How should the nurse further assess this finding using inspection? A. Palpate to measure the diameter of the mass B. Have the client cough forcefully a few times C. Ask the client to raise the head off the bed D. Percuss to determine if the mass is fluid filled
C. Ask the client to raise the head off the bed Explanation: Asking the client to raise the head off the bed will help the nurse to determine the location of the mass. A mass within the abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is obscured. Palpation and percussion should come after inspection is completed. Coughing will not assist the nurse with assessment of the abdominal mass. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Abdominal Wall Muscles, p. 498.
What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen? A. Inogastric B. Epigastric C. Hypogastric D. Hypochondriac
C. Hypogastric Explanation: The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right inguinal, hypogastric, and left inguinal. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Abdominal Quadrants, p. 497.
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? A. Relieved by drinking water B. Throbbing in nature C. May awaken the client at night D. Increased by intake of food
C. May awaken the client at night Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, History of Present Health Concern (continued), p. 502.
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? A. Any time of day is acceptable when using the umbilicus as a starting point B. Elevate the head of bed to concentrate the fluid in one area of the abdomen C. Measure at the same time each day, ideally in the morning after voiding D. Have the client lying down in the bed with the head of bed slightly elevated
C. Measure at the same time each day, ideally in the morning after voiding Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, ASSESSMENT GUIDE 23-2 Measuring Abdominal Girth, p. 525.
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? A. Adjust the bed level B. Hold the nurse's hands under warm water just before the examination C. Place the client's hand under the nurse's hand for a few moments D. Drape the client's genital area when the client is not being examined
C. Place the client's hand under the nurse's hand for a few moments Explanation: A ticklish client has trouble lying still and relaxing during the hands-on parts of the examination. Try to combat this using a controlled hands-on technique and by placing the client's hand under your own for a few moments at the beginning of palpation. Holding hands under warm water just before the hands-on examination is done to warm the hands. Draping the client's genital area is done for modesty. Adjusting the bed level would not help with ticklishness. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 508.
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's A. left lower quadrant. B. right lower quadrant. C. right upper quadrant. D. left upper quadrant.
C. right upper quadrant. Explanation: The liver is located in the right upper quadrant. Percuss the span or height of the liver by determining its lower and upper borders. The lower border of liver dullness is located at the costal margin to 1 to 2 cm below. To assess the lower border, begin in the RLQ at the mid-clavicular line (MCL) and percuss upward. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, STRUCTURE AND FUNCTION, pp. 498-499.
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what? A. Abdominal tumor B. Ascites C. Inflammation D. Abdominal aortic aneurysm
D. Abdominal aortic aneurysm Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Collecting Objective Data: Physical Examination, p. 512.
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? A. Internal abdominal oblique B. Peritoneum C. Transverse abdominis D. Linea alba
D. Linea alba Explanation: 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). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, Abdominal Wall Muscles, p. 498.
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? A. Encourage the client to increase PO fluid intake. B. Record the findings as expected for a client with an indwelling catheter. C. Flush the catheter tubing with sterile normal saline. D. Prepare to obtain a urine specimen for culture.
D. Prepare to obtain a urine specimen for culture. Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 504.
The nurse plans to assess a client's liver border. Which area of the abdomen is the nurse going to assess?
RUQ Explanation: The liver is located in the right upper quadrant of the abdomen. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 23: Assessing Abdomen, STRUCTURE AND FUNCTION, p. 498.
