Health Assessment ABD (PrepU)

How should the nurse perform blunt percussion over the liver? -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 radial 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 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. transverse abdominis. abdominal oblique. umbilical oblique.

-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.

Your patient 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 patient? 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.

The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the right side. This indicates ascites, which can be caused by Congestive heart failure and pyelonephritis Cirrhosis and nephrosis Metastatic neoplasms and coronary artery disease Congestive heart failure and coronary artery disease

Cirrhosis and nephrosis

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? Inadequate hydration Poor nutrition Higher fat-to-lean muscle ratio Decreased activity of protective bacteria in the urinary tract

Decreased activity of protective bacteria in the urinary tract

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 patient's abdomen to hear these bruits? (Select all that apply.) Right upper quadrant Femoral arteries Iliac arteries Epigastrium Costovertebral angles

Epigastrium Costovertebral angles Right upper quadrant

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

Fluid accumulating in the abdominal cavity

A 77-year-old retired bus driver presents at his wife's request to the clinic for a physical examination. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for more than 40 years. He denies any tobacco or drug use and has not drunk alcohol since getting married. His parents both died of cancer in their 60s. On examination his vital signs are in expected ranges. His head, cardiac, and pulmonary examinations are unremarkable. Abdominal examination reveals normal bowel sounds. Results of palpation of the liver are abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination? Smooth, large, nontender liver Irregular, large liver Smooth, large, tender liver

Irregular, large liver

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? 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 Inform the client that the pen mark on the abdomen should not be washed off Place the tape measure behind the client and measure at the umbilicus

Place the tape measure behind the client and measure at the umbilicus

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? Referred pain Radiated pain Localized 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.

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? Assist the client to the bathroom to empty the bladder Use percussion to determine the solidity of the structure Auscultate over the same area for the presence of a bruit 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 is preparing to palpate the client's spleen. What should the nurse instruct the client to do? Take a deep breath and hold it Take a deep breath and exhale Have the client lie on his left side Have the client lie on his right side

The client should be lying on his back and the nurse should ask the client to take a deep breath an exhale so that palpation can occur.

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? Peptic ulcer Cholecystitis Pancreatitis Appendicitis

appendicits

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 hyperactive Bowel sounds hypoactive Bowel sounds inconsistent

bowel sounds normal

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 Gastric ulcer Pancreatitis Gastroesophageal reflux

chron's disease

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

costovertebral angle

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

deep in the upper abdomen and is not normally palpable.

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? Discomfort Dysphagia Dyspepsia Odynophagia

dyspepsia

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? Sigmoid mass Tumour in the abdominal wall Hernia Enlarged bladder

enlarged bladder

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

gastric ulcer

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

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? ileus diarrhea peritonitis 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.

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

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.

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

large intestine

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

left upper quadrant

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. Stomach Liver Spleen Gallbladder Kidney

liver, spleen An increase in intestinal gas makes percussion of the liver and spleen more difficult. The stomach is already filled with air so this will not change the ability to percuss the organ. Gallbladder is not usually percussed. The kidney is percussed from the back & is not altered by an increase in intestinal gas.

Diagnostic tests completed validate that a client has an obstruction of the ascending and transverse colon. Where should the nurse assess for bowel sounds around the obstruction? Left upper quadrant Left lower quadrant Right upper quadrant Right lower quadrant

right upper quadrant The right upper quadrant is used to assess for the ascending and transverse colon. The left upper quadrant is used to assess the transverse and descending colon. The left lower quadrant is used to assess the descending and sigmoid colon. The right lower quadrant is used to assess the ascending colon.

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 Pancreas Gallbladder Liver

spleen

What is scaphoid shape of abdomen

stomach goes in while lying flat

When the nurse is obtaining a health history of the urinary system, the client reports "leaking" urine when coughing or laughing. Which of the following problems is the client likely experiencing? Urge incontinence Overflow incontinence Stress incontinence Obstructive incontinence

stress incontinence

A nurse suspects that a client has gastroesophygeal reflux disease (GERD). Which risk factors must be present for the nurse to confirm this? Select all that apply. body mass index greater than 30 taking multiple medications hiatal hernia alcohol consumption passing excess flatus

taking multiple medications hiatal hernia body mass index greater than 30 Risk factors for gastroesophygeal 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 palpate the abdomen before auscultation. listen in each quadrant for 15 seconds. use the diaphragm of the stethoscope. begin auscultation in the left upper quadrant.

use the diaphragm of the stethoscope.

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 toxic liver damage alcohol hepatitis intrahepatic jaundice

viral hepatitis