Nur 314 Chapter 20 Abdominal
A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? A. Murphy sign B. Psoas sign C. Rovsing sign D. Obturator sign
A. Murphy sign Rationale: The Murphy sign tests for gallbladder pain. Psoas, Rovsing, and obturator signs all test for peritoneal irritation in the lower quadrants.
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? A. Staphylococcus aureus B. Escherichia coli C. Streptococcus pyogenes D. Helicobacter pylori
D. Helicobacter pylori Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucous, on occasion the H. pylori disrupt the mucous lining and inflame the organ lining. The other bacteria listed are not associated with peptic ulcer disease.
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. "Have you been pregnant?" B. "Are you experiencing any abdominal pain?" C. "Have you noticed any color change to the skin?" D. "Do you have high blood pressure?"
A. "Have you been pregnant?" 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.
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what? A. Abdominal aortic aneurysm B. Abdominal tumor C. Ascites D. Inflammation
A. Abdominal aortic aneurysm 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.
A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen? A. Absent B. Hyperactive C. Hypoactive D. Erratic
A. Absent 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.
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 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 client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for? A. Acute pancreatitis B. Biliary colic C. Acute cholecystitis D. Acute diverticulitis
A. Acute pancreatitis With acute pancreatitis, epigastric pain may radiate to the back or other parts of the abdomen; it may be poorly localized.
The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? A. Appendicitis B. Inflammation of the gallbladder C. Liver engorgement D. Kidney pain
A. Appendicitis RLQ pain constitutes a positive obturator sign, suggesting an inflamed appendix or peritoneal inflammation. Kidney tenderness is assessed posteriorly. The Blumberg assesses for rebound tenderness and the Murphy test is for inflammation of the gallbladder.
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? A. Crohn's disease B. Gastric ulcer C. Pancreatitis D. Gastroesophageal reflux
A. Crohn's disease Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.
A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved? A. Gallbladder B. Kidneys C. Stomach D. Pancreas
A. Gallbladder Pain in the right upper quadrant along with referred pain to the right shoulder would suggest involvement of the gallbladder. Pain associated with the kidneys typically occurs in the flank and back. Pain associated with the stomach typically is epigastric. Pain associated with the pancreas is associated with epigastric pain and referred pain to the lower back.
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? A. Internal adhesions from previous surgery B. Intestinal obstruction at the sigmoid colon C. Acute onset of appendicitis with possible rupture D. Peritonitis from a ruptured diverticulum
A. Internal adhesions from previous surgery 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.
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound? A. It is a splenic rub. B. It is a variant of bowel noise. C. It represents borborygmi. D. It is a vascular noise.
A. It is a splenic rub. A rough, grating noise over this area represents a splenic rub, which can accompany splenic infarction. Rubs also occur over the liver and pleura and pericardium.
When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right MCL. Which organ is most likely involved? A. Liver B. Spleen C. Sigmoid colon D. Kidney
A. Liver Rationale: The spleen is normally found in the 9th to 11th left intercostal space (ICS) in the left midaxillary line (MAL). The colon is in the lower quadrants of the abdomen. The kidney is located in the posterior flank, in the lower rib cage. It is percussed for tenderness and is not always palpable.
The nurse assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C (99.3°F;). Which of the following interventions is appropriate for this client? A. Monitor pulse and blood pressure every 15 minutes until stable B. Assess for signs of hypervolemia C. Monitor intake and output and weights once a week D. Get a physical therapy consult
A. Monitor pulse and blood pressure every 15 minutes until stable The nurse should monitor this client's pulse and blood pressure every 15 minutes until stable. The nurse would assess for signs of hypovolemia including postural hypotension, poor skin turgor, thirst, sunken eyeballs, and weakness. Monitoring of intake and output and weights would happen daily. The client would not need physical therapy.
The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant with right flank pain. Which assessment should the nurse conduct next? A. Palpate the right lower quadrant for rebound tenderness. B. Test for a fluid wave. C. Assess for Murphy's sign. D. Assess for the obturator sign.
A. Palpate the right lower quadrant for rebound tenderness. Localized tenderness anywhere in the right lower quadrant, even in the right flank, suggests appendicitis. The nurse should follow this finding with an assessment of rebound tenderness. This will assist the nurse in determining if the client is guarding and develops muscle rigidity-two additional features of appendicitis. The test for fluid wave is used to identify ascites in the client. The manner in which the client presented does not warrant an assessment for ascites. Murphy's sign is used to assess for acute cholecystitis. A positive obturator sign can suggest inflammation of the appendix; however, this test has low sensitivity. For this reason, rebound tenderness should be assessed first.
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? A. Positive Rovsing's sign B. Psoas sign C. Obturator sign D. Positive skin hypersensitivity test
A. Positive Rovsing's sign 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.
The nurse understands that the liver does what? A. Produces clotting factors B. Secretes insulin C. Secretes amylase D. Secretes lipase
A. Produces clotting factors The liver produces clotting factors. The pancreas secretes insulin, amylase and lipase.
The client with a acute appendicitis has been ordered a barium enema. What should the nurse do first? A. Question the order as a barium enema is contraindicated in acute appendicitis B. Notify radiology of the order C. Obtained a signed consent from the client D. Make sure the client understands why the barium enema has been ordered
A. Question the order as a barium enema is contraindicated in acute appendicitis A barium enema should not be performed on a client suspected of having an acute inflammatory condition, such as appendicitis, diverticulitis, or ulcerative colitis, or who has a perforated hollow organ. The barium enema can cause an inflamed area of the bowel to rupture and death may result.
An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide? A. Quit smoking as soon as possible. B. Exercise for at least 30 minutes, three times per week. C. Eat several small meals a day rather than three larger meals. D. Attend screening clinics at least twice per year.
A. Quit smoking as soon as possible. Smoking cessation reduces the risk of PUD. Multiple small meals are not a preventative measure, and there are no current screening recommendations. Exercise has multiple health benefits, but prevention of PUD is not among them.
The nurse correctly identifies the gallbladder is located where? A. RUQ B. RLQ C. LUQ D. LLQ
A. RUQ
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? A. Referred pain B. Radiated pain C. Localized pain D. Chronic pain
A. 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.
When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication? A. Vitamin supplement with iron B. Nonsteroidal anti-inflammatory drug C. Antidepressant D. Hormone replacement
A. Vitamin supplement with iron The intake of iron can lead to constipation. Nonsteroidal anti-inflammatory drugs are associated with gastric bleeding. Antidepressants and hormonal replacements would be less likely to contribute to constipation.
When documenting a finding over the stomach, the nurse most accurately identifies the region as A. epigastric. B. hypogastric. C. RUQ. D. LLQ.
A. epigastric. Rationale: The epigastric region is located above the umbilicus and straddles the midline between the RUQ and LUQ. The hypogastric area, also known as the suprapubic, is the location of the bladder. RUQ is the area for the liver and gallbladder. The LLQ area is best for assessing the descending colon.
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's A. right upper quadrant. B. right lower quadrant. C. left upper quadrant. D. left lower quadrant.
A. right upper quadrant. 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.
Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is A. usually difficult to localize B. right or left sided C. more severe than parietal pain D. also called referred pain
A. usually difficult to localize Visceral pain occurs when hollow abdominal organs, such as the intestines, become distended or contract forcefully, or when the capsules of solid organs such as the liver and spleen are stretched. Poorly defined or localized and intermittently timed, this type of pain is often characterized as dull, aching, burning, cramping, or colicky.
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? A. viral hepatitis B. toxic liver damage C. alcohol hepatitis D. intrahepatic jaundice
A. viral hepatitis Travel to or consuming food meals in an area of poor sanitation can pose a risk for contracting viral hepatitis. This information paired with the client's report of having gray colored stools increases the likelihood of obstructive jaundice related viral hepatitis. Toxic liver damage can result from side effects of certain medications, inhaling or consuming industrial solvents, or exposure to environmental toxins. Alcohol hepatitis is secondary to alcohol abuse. Intrahepatic jaundice arises from damage to the hepatocytes or intrahepatic bile ducts.
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? A. "I'm going to examine the area where you're having pain first to get a better picture of what's going on." B. "Before I get ready to examine the painful area, I will let you know in plenty of time." C. "You don't need to worry about anything. I will make sure to be very gentle during the exam." D. "Since you're having pain in a certain area, I won't have to do a very thorough exam there."
B. "Before I get ready to examine the painful area, I will let you know in plenty of time." 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 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? A. Avoid eating overcooked foods B. Avoid excessive alcohol intake C. Avoid taking pain medications with food D. Avoid taking antacid medications
B. Avoid excessive alcohol intake 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.
Jim is a 60-year-old man who presents with vomiting. He denies any blood in his emesis, which has been present for 2 days. He does note a dark granular substance resembling the coffee left in the filter after brewing. What should the nurse suspect? A. Bleeding from a diverticulum B. Bleeding from a peptic ulcer C. Bleeding from colon cancer D. Bleeding from cholecystitis
B. Bleeding from a peptic ulcer When blood is exposed to the environment of the stomach, it often resembles "coffee grounds." This is not always recognized by clients as blood, so it is important to inquire about this. This symptom is not common in cholecystitis, and the other possibilities are lower in the intestine. It should be noted that conversely, a rapid bleed from the stomach or other upper gastrointestinal source can produce bright red blood in the stool. Do not rule out a proximal bleed based on the absence of "coffee grounds." Likewise, bright red blood in the emesis may originate from the stomach. Black, sticky stools also can accompany upper GI bleeds.
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? A. Ineffective Nutrition: Less Than Body Requirements B. Constipation related to decrease in fluid intake C. Ineffective Health Maintenance D. Risk for Fluid Volume Deficit
B. Constipation related to decrease in fluid intake 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.
On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity? A. Bleeding B. Fluid accumulation C. Inflammation D. Obstruction
B. Fluid accumulation Pale and taut skin indicates significant abdominal swelling caused by accumulation of fluid in the abdominal cavity, or ascites. Bleeding within the abdominal wall would manifest as purple discoloration at the flanks. Inflammation of the peritoneum and obstruction of the intestine does not contribute to pale and taut abdominal skin.
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. Peritoneum B. Linea alba C. Internal abdominal oblique D. Transverse abdominis
B. Linea alba 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).
A nurse performs percussion by placing the left hand flat against the client's lower rib cage and striking it with the ulnar side of the right fist. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ? A. Kidney B. Liver C. Spleen D. Gall bladder
B. Liver 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. Percussion of the spleen begins in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness. The gall bladder is not percussed.
A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test? A. Obturator B. Murphy's C. Psoas D. Rovsing's
B. Murphy's The gallbladder is located in the right upper quadrant of the abdomen. When it is inflamed (cholecystitis), performing the Murphy's sign will cause the client to hold the breath (inspiratory arrest). The Obturator & Psoas tests are to determine if the appendix is inflamed. Rovsing's sign test for rebound tenderness which may indicate peritoneal irritation.
A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor? A. Excessive fat and sugar intake B. Overuse of laxatives C. Obesity D. Inadequate abdominal muscle tone
B. Overuse of laxatives Overuse of laxatives may decrease intestinal tone and promote dependency, contributing to chronic constipation. Constipation is not attributable to low abdominal muscle tone. Obesity and excessive sugar and fat intake may exacerbate constipation but will not independently cause the health problem.
A patient with a history of cirrhosis tells the nurse that their abdomen seems to be getting larger and that they have gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? A. Listen for a fluid wave B. Percuss the abdomen for shifting dullness C. Auscultate for lymph nodes D. Stroke the abdomen to elicit the abdominal reflex
B. Percuss the abdomen for shifting dullness Rationale: Percussing elicits a change from tympany to dullness when the abdomen is in its most dependent position. Fat remains static. To assess for a fluid wave, the examiner would palpate, not auscultate. Lymph nodes are palpated, not auscultated. The abdominal reflex is utilized to assess motor neuron disease.
What would a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration? A. Hepatomegaly B. Splenomegaly C. Abdominal mass D. Intestinal air
B. Splenomegaly Normally, tympany or resonance is heard at the last left interspace. Dullness suggests splenomegaly. The liver would be percussed anteriorly. An increased liver span would suggest hepatomegaly. Percussion and palpation in any area of the abdomen might reveal an abdominal mass. Intestinal air would be noted by tympany.
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. This area should be avoided completely B. The left lower quadrant is palpated last C. Medicate for pain before beginning the assessment D. Encourage the client to relax to minimize pain
B. The left lower quadrant is palpated last 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.
A patient reports changes in bowel pattern. Which is the best question to determine normal bowel habits? A. How often do you have a bowel movement? B. What was your bowel pattern before you noticed the change? C. Is there a family history of IBS? D. Have any of your parents or siblings had cancer of the colon?
B. What was your bowel pattern before you noticed the change? Rationale: Determining the patient's bowel pattern before symptoms began is most valid in establishing the normal pattern. Knowing how often the patient moves their bowels provides information about only frequency, not consistency, color, and other characteristics of their bowel habits. Family history, including irritable bowel syndrome and colon cancer, do not address the patient's normal bowel habits.
To palpate the spleen of an adult client, the nurse should A. ask the client to exhale deeply. B. place the right hand below the left costal margin. C. point the fingers of the left hand downward. D. ask the client to remain in a supine position.
B. place the right hand below the left costal margin. To palpate the spleen stand at the client's right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the client's head. Ask the client to inhale and press inward and upward as you provide support with your other hand.
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? A. Absorbing electrolytes B. Secreting digestive enzymes C. Absorbing large amounts of water D. Secreting bile
C. Absorbing large amounts of water 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.
The nurse would assess for positive Blumberg sign how? A. Applying blunt pressure that the midclavicular line (MCL) B. Applying blunt pressure at the costovertebral angle (CVA) C. Applying and releasing pressure to the abdomen D. Having the client breathe deeply
C. Applying and releasing pressure to the abdomen 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.
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? A. Absent B. Hypoactive C. Borborygmus D. Erratic
C. Borborygmus 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.
Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect? A. Ascites B. Appendicitis C. Cholecystitis D. Splenomegaly
C. Cholecystitis A positive Murphy's signs is associated with acute cholecystitis. Tests for shifting dullness and fluid wave would help to identify ascites. Rebound tenderness, a positive Rovsing's sign, psoas sign, obturator sign, and positive hypersensitivity test would be associated with appendicitis. Splenomegaly would be noted with percussion and palpation.
A 46-year-old former salesman presents to the ER complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. Examination shows a man appearing older than his stated age. His skin has a yellowish tint and he is thin with a prominent abdomen. Multiple "spider angiomas" are at the base of his neck. Otherwise his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs? A. Infectious diarrhea B. Mallory-Weiss tear C. Esophageal varices
C. Esophageal varices Varices are often found in clients with alcoholism, but only when they have a diagnosis of significant cirrhosis. This client has symptoms of cirrhosis including jaundice, ascites, spider hemangiomas, and dilated veins noted on his abdomen (caput medusa).
A 23-year-old man has recently graduated from university and is preparing to embark on a backpacking trip around Southeast Asia. In preparation for his trip, the client has visited a clinic to obtain vaccinations. The client will be able to obtain vaccines protecting against which of the following? A. Hepatitis C B. Hepatitis B and C C. Hepatitis A and B D. Hepatitis A
C. Hepatitis A and B Vaccines are available for hepatitis A and B.
A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomiting. What assessment technique will elicit kidney pain? A. Inspection with indirect lighting B. Iliopsoas muscle sign C. Indirect percussion for CVA tenderness D. Blumberg sign
C. Indirect percussion for CVA tenderness Rationale: Fist percussion over the costovertebral angle (CVA) is the only technique listed that reflects a technique for assessing the kidney. The two specialty techniques, iliopsoas muscle sign and Blumberg sign, are used to assess peritoneal inflammation. Inspection will show distention, abnormal movements, and discoloration but will not elicit pain or tenderness.
When performing an abdominal assessment, what is the correct sequence? A. Inspection, palpation, percussion, auscultation B. Palpation, percussion, inspection, auscultation C. Inspection, auscultation, percussion, palpation D. Auscultation, inspection, palpation, percussion
C. Inspection, auscultation, percussion, palpation Rationale: Inspection always comes first. For the abdomen, auscultation must be performed before percussion and palpation to prevent changes in the bowel sounds due to manipulation.
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. Secretory infections B. Inflammatory infections C. Irritable bowel syndrome D. Malabsorption syndrome
C. Irritable bowel syndrome 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.
A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10-year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time? A. Inspect the abdomen for color, shape, and symmetry B. Obtain a complete set of vital signs and pain assessment C. Listen with the bell of the stethoscope for vascular sounds D. Observe for evidence of increased abdominal girth
C. Listen with the bell of the stethoscope for vascular sounds A client with a history of hypertension is at risk for bruits over any of the vascular areas on the abdomen such as renal artery, iliac artery, or femoral artery. The bell of the stethoscope is used for this assessment since bruits are low-pitched murmur-like sounds. Inspection of the abdomen should be performed before auscultation. Vital signs are part of the general survey and are usually the first hands on assessment of a client. measuring abdominal girth is done if the nurse observes a distended abdomen or there are other signs of fluid retention within the abdomen.
You are assessing a client for acute cholecystitis. What sign would you assess for? A. Psoas sign B. Obstipation sign C. Murphy sign D. Cutaneous hyperesthesia
C. Murphy sign 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.
During the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign? A. Obturator B. Psoas C. Murphy's D. Rovsing's
C. Murphy's Murphy's sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. The obturator sign involves pain in the right lower quadrant as a result of the nurse flexing the client's hip and rotating the leg externally and internally while supporting the client's right knee and ankle. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.
When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? A. Right renal artery B. Right femoral artery C. Right iliac artery D. Abdominal aorta
C. Right iliac artery Rationale: The iliac arteries are located to the left and right of the midline of the abdomen, below the umbilicus. The aorta is midline, the renal artery is above the umbilicus, and the femoral artery is located in the groin.
The nurse is evaluating a new graduate's ability to perform a rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location? A. Right upper quadrant B. Left upper quadrant C. Right lower quadrant D. Left lower quadrant
C. Right lower quadrant The appendix is located in the right lower quadrant. If the client has appendicitis, pressing deeply in this location with a sudden release of pressure will elicit a sharp, stabbing pain, which is called "rebound tenderness."
The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location? A. Right upper quadrant B. Left upper quadrant C. Right lower quadrant D. Left lower quadrant
C. Right lower quadrant The appendix is located in the right lower quadrant. If the client has appendicitis, pressing deeply in this location with a sudden release of pressure will elicit a sharp, stabbing pain, which is called "rebound tenderness."
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? A. Gallbladder B. Liver C. Spleen D. Head of pancreas
C. Spleen 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 young client presents with a left-sided mass in her abdomen. It is present in the left upper quadrant. Which of the following would support that this represents an enlarged kidney rather than her spleen? A. A palpable "notch" along its edge B. The inability to push fingers between the mass and the costal margin C. The presence of normal tympany over this area D. The ability to push fingers medial and deep to the mass
C. The presence of normal tympany over this area A left upper quadrant mass is more likely to be a kidney if there is no palpable "notch"; the examiner can push the fingers between the mass and the costal margin; there is normal tympany over this area; and the examiner cannot push the fingers medial and deep to the mass. These findings are very difficult to appreciate in an obese client.
During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should A. palpate the abdomen before auscultation. B. listen in each quadrant for 15 seconds. C. use the diaphragm of the stethoscope. D. begin auscultation in the left upper quadrant.
C. use the diaphragm of the stethoscope. Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client's abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants.
Which assessment technique best confirms splenic enlargement? A. Deep palpation under the left costal margin B. Fist percussion of the spleen with the patient in a sitting position C. Deep palpation over the RUQ with the patient lying on the right side D. Percussion along the left MAL spleen and gentle palpation
D. Percussion along the left MAL spleen and gentle palpation Rationale: Percussion is the best technique to estimate the size of the spleen; gentle palpation is necessary to reduce the risk of splenic rupture. Deep palpation can cause splenic rupture, and the left costal margin is the location of the stomach. Fist percussion is used to elicit pain to assess for kidney tenderness. Palpation of the RUQ is the area to assess for the liver and gallbladder.
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? A. Refer the client to an oncologist. B. Provide a dietician consult for the client. C. Counsel the client regarding hernia repair. D. Stop palpating and get medical assistance.
D. Stop palpating and get medical assistance. 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.
What percussion sound is heard over most of the abdomen? A. Resonance B. Hyperresonance C. Dullness D. Tympany
D. Tympany Rationale: The small intestine and colon, which are hollow organs filled with air and fluid, are predominant over most of the abdominal cavity. The result is tympany as the percussion sound. Resonance is heard over air-filled organs such as the lungs. Hyperresonance is an abnormal sound in the adult. Dullness is heard over solid organs such as the liver and muscles.
The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the A. right upper quadrant. B. left upper quadrant. C. external oblique angle. D. costovertebral angle.
D. costovertebral angle. Kidney tenderness is best assessed at the costovertebral angle.
While auscultating rushes of high-pitched bowel sounds a client complains of abdominal pain. What should the nurse suspect is occurring with this client? A. ileus B. diarrhea C. peritonitis D. intestinal obstruction
D. 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.
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should A. perform this abdominal assessment first. B. ask the client to assume a side-lying position. C. palpate lightly while slowly releasing pressure. D. palpate deeply while quickly releasing pressure.
D. palpate deeply while quickly releasing pressure. If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen away from the painful or tender area. Then suddenly release pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred.
A nurse is performing an admission assessment on a new client. The client reports black tarry stools and abdominal pain immediately after eating. What condition would the nurse suspect? A. Crohn disease B. indigestion C. constipation D. peptic ulcer
D. peptic ulcer Peptic ulcer presents with abdominal pain immediately after eating (gastric ulcer) and possibly black tarry stools if bleeding is occurring. Signs and symptoms of Crohn disease include weight loss and malnutrition. Indigestion, also referred to as GERD, presents with signs and symptoms of hyperacidity after eating large meals. Abdominal pain immediately after eating and black tarry stools are not signs and symptoms of constipation.
To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's A. left upper quadrant. B. left lower quadrant. C. right upper quadrant. D. right lower quadrant.
D. right lower quadrant.
A 42-year-old florist comes to the office complaining of chronic constipation for the last 6 months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies any recent illnesses or injuries. She denies any changes to her diet or exercise program. She is on no new medications. During review of systems the client says that she has felt fatigued, had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one vaginal delivery and two c-sections. She is married with three children and she owns her own flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has coronary artery disease. There is no family history of cancers. On examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the Achilles tendons. What is the best choice for the cause of her constipation? Large bowel obstruction
Hypothyroidism Many metabolic conditions can interfere with bowel motility. In this case the client has many symptoms of hypothyroidism including cold intolerance, weight gain, fatigue, constipation, and irregular menstrual cycles. On examination, thyromegaly and delayed reflexes can help to make the diagnosis. Medication will usually correct these symptoms.
