NUR 3065 PrepU Chapter 16

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 Absent Borborygmus Hyperactive

Absent Explanation: 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."

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? Absorbing electrolytes Secreting digestive enzymes Secreting bile Absorbing large amounts of water

Absorbing large amounts of water Explanation: The colon functions primarily to secrete large amounts of alkaline mucus to lubricate the intestine and neutralize acids formed by the intestinal bacteria. Water is also absorbed through the large intestine, leaving waste products to be eliminated in stool. The colon does not secrete enzymes or bile, and it does not absorb significant quantities of electrolytes.

Before concluding a client's assessment the nurse performs the technique shown. For what is the nurse assessing in this client? **picture question, picture is of a nurse maybe stretching the right leg backwards, words her*** Hip joint dislocation Appendicitis Small bowel obstruction Kidney stones

Appendicitis Explanation: Hyperextending the client's right leg is an assessment for the psoas sign. If pain occurs in the right upper quadrant, this is associated with irritation of the iliopsoas muscle due to appendicitis. This technique is not used to assess for kidney stones, a hip joint location, or a small bowel obstruction.

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? Peritoneal irritation Appendicitis Inflamed gall bladder Liver inflammation

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.

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? Appendicitis Pancreatitis Cholecystitis Peptic ulcer

Appendicitis Explanation: This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.

The nurse would assess for positive Blumberg sign how? Applying and releasing pressure to the abdomen Applying blunt pressure that the midclavicular line (MCL) Having the client breathe deeply Applying blunt pressure at the costovertebral angle (CVA)

Applying and releasing pressure to the abdomen Explanation: Pain that occurs after applying and releasing pressure to the abdomen would be a positive Blumberg sign. Murphy sign occurs when the client holds his breath and there is pain. Blunt pressure at the CVA assesses for kidney pain. Liver span test occurs at the MCL.

A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend? Avoid taking antacid medications Avoid taking pain medications with food Avoid eating overcooked foods Avoid excessive alcohol intake

Avoid excessive alcohol intake Explanation: The nurse should recommend avoiding excessive alcohol intake, as this is a risk factor associated with peptic ulcer disease. The nurse should also recommend eating foods that have been cooked completely and taking pain medications with food. Antacid medications may relieve peptic ulcers.

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? Hypoactive Absent Borborygmus Erratic

Borborygmus Explanation: 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." Erratic is not a type of bowel sound.

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

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.

A college student presents to the health care clinic with reports no bowel movement for four (4) days, bloating, and generalized abdominal discomfort. She states she has not been eating and drinking correctly and is stressed because she has a final exam in two (2) days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants, tenderness in the left lower quadrant with a few small round, firm masses. Rovsing's sign and the Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client? Constipation related to decrease in fluid intake Ineffective Health Maintenance Risk for Fluid Volume Deficit Ineffective Nutrition: Less Than Body Requirements

Constipation related to decrease in fluid intake Explanation: The nurse can confirm constipation because the major defining characteristics of decreased frequency and abdominal discomfort are present. A few days of altered nutrition does not meet the necessary criteria to confirm Ineffective Nutrition or risk for Fluid Volume Deficit. Ineffective Health Maintenance cannot be confirmed because there is no evidence that the client lacks the knowledge to eat properly.

The nurse assess for kidney tenderness at what location? Hypogastric area Midclavicular line Umbilical region Costovertebral angle

Costovertebral angle Explanation: Blunt percussion at the costovertebral angle assesses for kidney tenderness. The liver is assessed at the midclavicular line. The hypogastric and umbilical regions are incorrect areas to assess for kidney pain.

The nurse documents that a client's abdomen is scaphoid in shape. Which diagram best describes the client's abdomen? *picture question*

Explanation: A scaphoid abdomen caves in and is usually seen in thin clients. A flat abdomen is not caved in or distended. A rounded abdomen is seen in overweight or obese clients. A distended/protuberant abdomen may be associated with obesity, ascites, or a tumor on an abdominal organ. From google: A condition in which the anterior abdominal wall is sunken and presents a concave rather than a convex contour. Synonym(s): navicular abdomen.

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

Gastric ulcer Explanation: Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.

A nurse is working with an older client who has had diarrhea for the past week and is dehydrated. The nurse understands that older clients are especially at risk for potential complications with diarrhea due to which of the following factors? Decreased sensitivity to pain Tendency to have an inadequate fluid intake Large numbers of medications taken Higher fat-to-lean muscle ratio

Higher fat-to-lean muscle ratio Explanation: Older adult clients are especially at risk for potential complications with diarrhea, such as fluid volume deficit, dehydration, electrolyte, and acid-base imbalances, because they have a higher fat-to-lean muscle ratio. It is not established that older adults have a tendency to have an inadequate fluid intake. An increased number of medications taken would not explain increased risk for potential complications with diarrhea, and neither would decrease sensitivity to pain.

What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen? Inogastric Hypogastric Hypochondriac Epigastric

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.

A client presents to the emergency department with reports of new onset of abdominal pain for the past three (3) days. The client states there is also a pulling feeling on the right side. Upon examination the nurse notices a 5cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process? Internal adhesions from previous surgery Intestinal obstruction at the sigmoid colon Peritonitis from a ruptured diverticulum Acute onset of appendicitis with possible rupture

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.

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

Listen for a total of 5 minutes Explanation: Bowel sounds normally occur every 5 to 15 seconds. In a client with nausea and vomiting, bowel sounds may be hypoactive. The nurse should listen for a total of 5 minutes to confirm the absence of bowel sounds. Assessing the client for dehydration is necessary but not in relation to the finding of bowel sounds. Palpation should be done after completing auscultation of the abdomen.

Your client 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 client? Crohn disease Malabsorption syndrome Lactose intolerance Ulcerative colitis

Malabsorption syndrome Explanation: 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.

What can cause bladder distention? (Mark all that apply.) Rectal abscess Perineal fissure Multiple sclerosis Stroke Medications

Medications Stroke Multiple sclerosis Explanation: Bladder distention results from outlet obstruction due to urethral stricture or prostatic hyperplasia, and also from medications and neurologic disorders such as stroke or multiple sclerosis.

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

Middle of the ventral abdominal wall Explanation: Four layers of large, flat muscles form the ventral abdominal wall and are joined at the midline by a tendinous seam, the linea alba. The lower edge of the costal margin and the anterosuperior iliac spine of the iliac bones are landmarks used to divide the abdomen into regions. The abdomen is a large cavity extending from the xiphoid process of the sternum down to the superior margin of the pubic bone.

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

Murphy sign Explanation: A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.

Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure? Urge incontinence Stress incontinence Functional incontinence Overflow incontinence

Overflow incontinence Explanation: Stress incontinence with increased intra-abdominal pressure suggests decreased contractility of the urethral sphincter or poor support of bladder neck; urge incontinence, if unable to hold the urine, suggests detrusor overactivity; overflow incontinence, when the bladder cannot be emptied until bladder pressure exceeds urethral pressure, indicates anatomic obstruction by prostatic hypertrophy or stricture, or neurogenic abnormalities.

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 interprets this as which of the following? Psoas sign Obturator sign Positive skin hypersensitivity test Positive Rovsing's sign

Positive Rovsing's sign Explanation: Findings indicating referred rebound tenderness is a positive Rovsing's sign. Psoas sign occurs when pain in the right lower quadrant occurs with raising of the client's right leg from the hip and pressure applied downward against the lower thigh. The obturator sign occurs when pain in the right lower quadrant results when the client's right knee and ankle are supported and the leg is rotated internally and externally. A positive hypersensitivity test occurs when the client experiences pain or exaggerated sensation when the abdomen is stroked with a sharp object.

When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant? Right ovary, descending colon, and spleen Right kidney, transverse colon, and inguinal ligament Right ovary, pancreas, and sigmoid colon Right kidney, ascending colon, and liver

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.

Which nursing diagnosis is most appropriate for an elderly client with poor dentition? Risk for Imbalanced Nutrition: Less Than Body Requirements Diarrhea Constipation Fluid volume deficit

Risk for Imbalanced Nutrition: Less Than Body Requirements Explanation: A client with poor dentition is at risk for Imbalanced Nutrition: Less Than Body Requirements as teeth may be missing or chewing may be difficult. None of the other diagnosis are related to poor dentition.

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant? Liver Gallbladder Head of pancreas Spleen

Spleen Explanation: The spleen is located in the left upper quadrant. The gallbladder, liver, and head of the pancreas are located in the right upper quadrant.

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? Gall bladder Spleen Kidney Liver

Spleen Explanation: Percussion of the spleen begins in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness. Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage and striking it with the ulnar side of the right fist. 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. The gall bladder is not percussed.

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? Stop palpating and get medical assistance. Provide a dietician consult for the client. Refer the client to an oncologist. Counsel the client regarding hernia repair.

Stop palpating and get medical assistance. Explanation: If the nurse palpates a prominent pulsating mass, the suspicion is high for an abdominal aortic aneurysm. The nurse should stop palpating immediately and seek medical assistance because the risk of rupture is great. The mass does not suggest a malignancy or hernia, nor does it indicate a need for a dietary consult.

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus? Counsel the client regarding hernia repair. Stop palpating and get medical assistance. Refer the client to an oncologist. Provide a dietician consult for the client.

Stop palpating and get medical assistance. Explanation: If the nurse palpates a prominent pulsating mass, the suspicion is high for an abdominal aortic aneurysm. The nurse should stop palpating immediately and seek medical assistance, because the risk of rupture is great. The mass does not suggest a malignancy or hernia, nor does it indicate a need for a dietary consult.

A 52-year-old secretary comes to the office complaining about accidentally leaking urine when she coughs or sneezes. She says this has been going on for about 1 year. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is significant for four spontaneous vaginal deliveries. She is married with four children. She denies alcohol, tobacco, or drug use. Pelvic examination reveals some atrophic vaginal tissue but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable. Which type of urinary incontinence does she have? Stress incontinence Functional incontinence Urge incontinence Overflow incontinence

Stress incontinence Explanation: Stress incontinence usually occurs when the intra-abdominal pressure goes up during coughing, sneezing, or laughing. This is usually from a weakness of the pelvic floor with inadequate muscle support of the bladder. Vaginal deliveries and pelvic surgery are often associated with these symptoms. Usually female clients are postmenopausal when stress incontinence begins. Kegel exercises are usually recommended to strengthen the pelvic floor muscles.

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

Suprapubic Explanation: Bladder disorders may cause suprapubic pain.

Mrs. LaFarge, 60 years old, presents with urinary incontinence. She cannot get to the bathroom quickly enough when she senses the need to urinate. She has normal mobility. Which of the following is most likely? Overflow incontinence Stress incontinence Functional incontinence Urge incontinence

Urge incontinence Explanation: Stress incontinence occurs with increased intraabdominal pressure such as with coughing, sneezing, or laughing. This history is most consistent with urge incontinence secondary to detrusor overactivity. Overflow incontinence occurs with anatomical obstruction such as prostatic hypertrophy (obviously not in this case, as the client is a woman), urethral stricture, or neurogenic bladder. Functional incontinence results from lack of mobility severe enough to impair getting to the bathroom quickly enough.

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem? Symmetric appearance Visible peristaltic waves Abdominal respiratory movements No bulging with head raising

Visible peristaltic waves Explanation: Visible peristaltic waves typically are not visible except in very thin people. An increase in peristaltic waves with progression in a ripple like fashion suggests intestinal obstruction, necessitating further evaluation. Abdominal respiratory movements are normal findings in a male client. Symmetric appearance and absence of bulging when the client raises his head are also normal findings.

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

ask the client to empty his bladder. Explanation: Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination.

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

costovertebral angle. Explanation: Kidney tenderness is best assessed at the costovertebral angle.

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

left lower quadrant. Explanation: The left lower quadrant (LLQ) contains the left kidney (lower pole), left ovary and tube, left ureter, left spermatic cord, and descending and sigmoid colon.

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

left upper quadrant. Explanation: The spleen is located in the left upper quadrant.

A client has COPD. On examination, the nurse would expect liver dullness to be displaced downward the liver span to be decreased difficulty in percussing liver dullness the liver to be enlarged

liver dullness to be displaced downward

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

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.

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? "I'm going to examine the area where you're having pain first to get a better picture of what's going on." "Before I get ready to examine the painful area, I will let you know in plenty of time." "Since you're having pain in a certain area, I won't have to do a very thorough exam there." "You don't need to worry about anything. I will make sure to be very gentle during the exam."

"Before I get ready to examine the painful area, I will let you know in plenty of time." Explanation: The nurse would determine which area or areas are causing the client discomfort or pain and assess those areas last. In addition, the nurse would reassure the client that he or she will forewarn the client when the areas will be examined. The nurse need to approach the client with slow, gentle, and fluid movements. Telling the client not to worry is inappropriate even if the nurse will be gentle during the examination. The area of pain requires just as thorough an exam as other areas and possibly a more in-depth examination if necessary.

A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says "I should discontinue the iron tablets and eat foods that are high in iron." "I can decrease the constipation if I eat foods high in fiber and drink water." "Constipation should decrease if I take the iron tablets with milk." "I should cut down on the number of iron tablets I am taking each day."

"I can decrease the constipation if I eat foods high in fiber and drink water." Explanation: High iron intake may lead to chronic constipation.

A client presents at the clinic with a chief complaint of "indigestion." The client tells the nurse, "It usually happens after I do things like mowing the lawn or doing other yard work." What should the nurse suspect? Angina Ulcer disease Gallbladder disease Aortic aneurysm

Angina Explanation: Note that angina from inferior wall coronary artery disease may present as "indigestion," but is precipitated by exertion and relieved by rest.