Health Assessment-Chapter 22-Abdomen

Which problem would the nurse expect to find in a patient with dysphagia? 1 Difficulty in swallowing 2 Loss of weight and appetite 3 Intolerance to milk products 4 Burning sensation in the esophagus

1 Difficulty in swallowing Dysphagia may be related to disorders of the throat or esophagus; therefore a patient with dysphagia will have difficulty swallowing. The patient with anorexia has a loss of appetite leading to weight loss. Anorexia may occur because of gastrointestinal disease, as a side effect to some medications, with pregnancy, or with mental health disorders. Lactase deficiency leads to intolerance to milk products, and a patient with this deficiency may experience bloating or flatulence after consuming milk products. Pyrosis or heartburn is a burning sensation in the esophagus or stomach resulting from the reflux of gastric acid.

Which are the normal features of the spleen? Select all that apply. 1 It lies under the diaphragm. 2 It is a palpable visceral organ. 3 It lies parallel to the tenth rib. 4 It extends to the lower quadrants. 5 It is a soft mass of lymphatic tissue.

1 It lies under the diaphragm. 3 It lies parallel to the tenth rib. 5 It is a soft mass of lymphatic tissue. The spleen lies in the posterolateral wall of the abdominal cavity, immediately under the diaphragm. It lies obliquely with its long axis behind and parallel to the tenth rib, lateral to the midaxillary line. It is about 7 cm wide and extends from the ninth to the eleventh rib. It is a soft mass of lymphatic tissue. It is a solid visceral organ that is not palpable normally. It is palpable only if it is enlarged. The spleen normally occupies the left upper quadrant. If it becomes enlarged, its lower pole moves downward and toward the midline, extending to the lower quadrants.

Which internal organs constitute the solid viscera? Select all that apply. 1 Liver 2 Colon 3 Kidneys 4 Ovaries 5 Stomach

1 Liver 3 Kidneys 4 Ovaries Solid viscera are those organs that maintain a characteristic shape. The liver, ovaries, and kidneys are some of the organs that constitute the solid viscera. The liver occupies most of the right upper quadrant and extends over to the left midclavicular line. The lower edge of the liver and the right kidney normally may be palpable. The ovaries normally are palpable only on bimanual examination. The colon and stomach constitute the hollow viscera. The shape of the hollow viscera depends on their contents. The colon is usually not palpable but can be felt if it is distended with feces. The stomach lies just below the diaphragm, between the liver and the spleen. - Liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus

Which finding would the nurse relate to Cushing syndrome during an assessment? 1 Purple-blue striae 2 Silvery white striae 3 Cutaneous angiomas 4 Brown macular areas

1 Purple-blue striae A patient with Cushing syndrome is likely to have purple-blue striae on the skin. The skin is fragile and easily broken from normal stretching because of the presence of excess adrenocortical hormone. Striae occur when elastic fibers in the reticular layer of the skin are broken because of rapid or prolonged stretching. Pregnancy or excessive weight gain can also cause striae. They are pink or blue initially; then they turn silvery white. Cutaneous angiomas, or spider nevi, occur with portal hypertension or liver disease. Pigmented nevi or moles are commonly found on the abdomen. They are circumscribed brown macular or papular areas.

Which action would the nurse take to assess the symmetry of the patient's abdomen? 1 Shine a light lengthwise across the patient. 2 Ask the patient to exhale and hold the breath. 3 Shine a light away from self across the abdomen. 4 Ask the patient to perform a sit-up with both hands.

1 Shine a light lengthwise across the patient. The nurse would shine a light lengthwise across the patient. This enables the bulges to be highlighted by their shadows. The patient would not exhale and hold the breath, but take a deep breath so that the nurse can identify localized bulging. If the nurse shines the light across the abdomen away from self, the nurse will not be able to see the shadows of the bulges. Therefore the nurse shines the light across the abdomen toward self. The nurse may ask the patient to perform a sit-up without pushing up with the hands to identify changes in the contour of the abdomen. The deep breath and sit-ups enable the nurse to identify the presence of hernia, enlarged liver, or spleen.

The nurse is assessing a patient for the presence of free fluids in the peritoneal cavity. Arrange the steps of the fluid wave test in the order in which the nurse would implement them. 1. The patient is assisted to a supine position. 2. The nurse stands on the patient's right side. 3. The patient places a hand firmly on the midline of the abdomen. 4. The nurse strikes the patient's left flank with the right hand. 5. The nurse places the left hand on the patient's right flank.

1,2,3,5,4 The nurse assesses the patient for ascites, or the presence of free fluids in the peritoneal cavity, by using the fluid wave test. First, the patient is assisted to a supine position. In this position, ascitic fluid settles by gravity into the flanks, displacing the air-filled bowel to the periumbilical region. The nurse stands at the patient's right and instructs the patient to place the ulnar edge of the hand firmly on the abdomen in the midline. The nurse places the left hand on the patient's right flank. The nurse then reaches out across the patient's abdomen to strike the left flank with the right hand. If ascites is present, the blow will generate a fluid wave through the abdomen. In a positive test, the nurse will feel a distinct tap on the left hand.

Which abdominal assessment would the nurse use to confirm rebound tenderness? 1 Murphy sign 2 Blumberg sign 3 Obturator test 4 Iliopsoas muscle test

2 Blumberg sign The nurse assesses the abdomen for rebound tenderness using the Blumberg sign by choosing a site away from the painful area and holding the hand perpendicular to the abdomen. The nurse then pushes down slowly and deeply, and then lifts up quickly. This makes the structures that are indented by palpation rebound suddenly. A positive response is pain on release of pressure, indicating peritoneal inflammation. Murphy sign is used to assess the inspiratory arrest in a patient with cholecystitis. The obturator test is a technique that stretches the obturator muscle. The iliopsoas muscle test is used to test for an inflamed iliopsoas muscle, which occurs with an inflamed or perforated appendix.

Which are changes in the gastrointestinal system because of aging? Select all that apply. 1 Increased salivation 2 Decreased liver size 3 Decreased sense of taste 4 Impaired drug metabolism 5 Rapid esophageal emptying

2 Decreased liver size 3 Decreased sense of taste 4 Impaired drug metabolism Several changes, such as a decrease in liver size, occur in the gastrointestinal system because of aging. The liver decreases by 25% between 20 and 70 years of age. The aging adult also has a decreased sense of taste following a decrease in salivation. In addition, the liver is unable to metabolize drugs effectively because of the reduced size of the liver and reduced blood flow through it. The aging adult has decreased, not increased, salivation, which causes dry mouth. The aging adult experiences a delay in esophageal emptying that can cause aspiration if the individual is fed in a supine position.

Which finding of an umbilical cord during a newborn's assessment is cause for concern? 1 It is white at birth. 2 It has one artery and one vein. 3 It contains Wharton's jelly. 4 The stump dries within one week.

2 It has one artery and one vein. The umbilical cord contains two arteries and one vein at birth. The presence of a single artery indicates the risk for congenital defects. The cord is usually white at birth. Normally, the arteries and the vein are surrounded by a mucoid connective tissue called Wharton's jelly. The umbilical stump usually dries up within one week, hardens, and falls off by 10 to 14 days. The area is covered by skin in 3 to 4 weeks.

Which statements would the nurse include when teaching an aging adult about prevention of constipation? Select all that apply. 1 "Include high-fat food in the diet." 2 "Include low-fiber foods in the diet." 3 "Do not retain stool deliberately." 4 "Participate in physical exercise." 5 "Drink an adequate quantity of water."

3 "Do not retain stool deliberately." 4 "Participate in physical exercise." 5 "Drink an adequate quantity of water." To prevent constipation, the patient would drink adequate water to ease digestion and prevent hardening of stools. The aging adult often retains stool deliberately because of difficulty in ambulating to the toilet. This makes the stool hard and difficult to pass. Therefore the nurse would encourage the patient to use the toilet when required. Because lack of mobility and physical exercise leads to constipation, the nurse would ask the patient to engage in physical activity to promote bowel movements. The nurse would not encourage increased intake of high-fat food, which can lead to obesity. The patient would include high-fiber food in the diet to prevent constipation.

Which action would the nurse take while auscultating the abdomen of a patient? 1 Push the stethoscope against the skin. 2 Auscultate the abdomen after palpation. 3 Auscultate using the diaphragm endpiece. 4 Begin auscultation from the left upper quadrant.

3 Auscultate using the diaphragm endpiece. The nurse would auscultate the abdomen using the diaphragm endpiece, because the bowel sounds are relatively high-pitched. Percussion and palpation can increase peristalsis and give a false interpretation of the bowel sounds. Therefore the nursing assessment order for examination of the abdomen is inspection, auscultation, percussion, and palpation. The nurse would not push the stethoscope against the skin, to avoid stimulation of more bowel sounds. Therefore the nurse holds the stethoscope lightly against the skin. The nurse would begin auscultation in the right lower quadrant (RLQ) and not the left upper quadrant (LUQ). This is because bowel sounds are normally present at the ileocecal valve area in the RLQ.

Which finding is consistent with sudden onset of severe colicky pain in the lower abdomen? 1 Appendicitis 2 Cholecystitis 3 Kidney stones 4 Gastroenteritis

3 Kidney stones Kidney stones cause a sudden onset of severe pain in the lower abdomen. Appendicitis typically starts as a dull, diffuse pain in the periumbilical region. The pain then shifts to severe, sharp, and persistent pain with tenderness that is localized in the right lower quadrant. Cholecystitis is biliary colic, sudden pain in the right upper quadrant that may radiate to the right or left scapula. The patient with gastroenteritis has diffuse and generalized pain accompanied by nausea and diarrhea.

Which soft, lobulated gland is located behind the stomach? 1 Liver 2 Spleen 3 Pancreas 4 Gallbladder

3 Pancreas The pancreas is a soft, lobulated gland located behind the stomach. It stretches obliquely across the posterior abdominal wall to the left upper quadrant. The liver fills most of the right upper quadrant and extends over to the left midclavicular line. The spleen is a soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity. It lies just under the diaphragm. The gallbladder rests under the posterior surface of the liver, just lateral to the right midclavicular line.

Which stool color is expected for a patient who is taking an iron supplement? 1 Gray stool 2 Tarry black stool 3 Red blood in stool 4 Nontarry black stool

4 Nontarry black stool The color and consistency of the stool changes with intake of iron supplements, and the nurse would teach the patient to expect nontarry black stool when taking this medication. Gray stools occur with hepatitis. The patient may experience tarry black stools in the presence of occult blood or melena from gastrointestinal bleeding. Red blood may be found in stools in the presence of gastrointestinal bleeding or localized bleeding around the anus.

Which condition during auscultation is associated with a very loud splash in the upper abdomen of an infant who is being rocked from side to side? 1 Peritonitis 2 Brisk diarrhea 3 Gastroenteritis 4 Pyloric obstruction

4 Pyloric obstruction The succussion splash is a very loud splash auscultated over the upper abdomen when the infant is rocked from side to side. It indicates the presence of increased air and fluid in the stomach, which is often seen with pyloric obstruction. Peritonitis causes diminished or absent bowel sounds, indicating decreased motility as a result of inflammation. Borborygmi are loud, gurgling sounds that indicate increased motility and occur with brisk diarrhea and gastroenteritis.

Which organ is located in all four quadrants of the abdomen? 1 Liver 2 Ovary 3 Stomach 4 Small Intestine

4 Small Intestine The abdominal wall is divided into four quadrants by imaginary vertical and horizontal lines bisecting the umbilicus. The small intestine extends from the pyloric valve of the stomach to the ileocecal valve, where it joins the colon. Thus the small intestine is located in all four quadrants. The liver occupies most of the right upper quadrant. The right ovary and tube lie in the right lower quadrant, whereas the left ovary and tube lie in the left lower quadrant. The stomach is in the left upper quadrant.