UPREP CH. 20/23. VSIM VERNON RUSSELL

Mr. Russell asks the nurse, "What is the purpose of these passive range-of-motion (ROM) exercises? I can move my own arms and legs." What is the correct response by the nurse?

"Passive range-of-motion exercises will help you to maintain mobility in your joints." Rationale:The nurse would explain to Mr. Russell that the passive range-of-motion exercises will help him to maintain mobility in his joints. The purpose of passive range-of-motion exercises is not to prevent clot formation or skin breakdown. Mr. Russell is not confined to bed and can ambulate with the help of a walker.

The nurse is assessing a patient for fall risk. Which factor(s) would place the patient at a higher risk for falls? (Select all that apply.)

depression, gait or balance impairment, use of more than four prescription medications. Rationale:Factors that place a patient at higher risk for falls include depression, gait or balance impairment, and use of four or more prescription medications. Female gender, rather than male, puts the patient at higher risk. Patients age 80 or over are also at higher risk for falls.

An older adult male client reports difficulty urinating (hesitancy, urgency, and frequency). The nurse determines these symptoms are most likely related to which of the following physiological changes that commonly occur as men age?

enlarged prostate gland. As men age, the prostate gland increases in size, narrowing the lumen of the urethra, constricting the outflow of urine, and causing urine retention, hesitancy, urgency, and frequency. Signs and symptoms of bladder cancer include painless bright red bleeding (frank hematuria). Kidney stones obstruct urine output, causing urine to back up into the kidneys and leading to hydronephrosis; clients with kidney stones experience sharp, colicky pain as the stone moves through the urinary tract. There are various causes of urinary restrictive disorders (including enlarged prostate gland), but this is not the best option. The physiologic change that is causing the underlying problems is the enlargement of the prostate gland.

The nurse is assessing the genitalia of an adult male client when he tells the nurse that his testes are swollen and painful. The nurse should refer the client to a physician for possible

epididymitis. In epididymitis the scrotum appears enlarged, reddened, and swollen.

While reviewing the medical record before examining a male clinic client, the nurse notes that the urinary meatus is located on the top of the glans of the penis. The nurse understands the correct term for this congenital defect is

epispadias.

spermatic cord

extends upward from the epididymis and is attached to each testicle

prolapse

falling or dropping down of an organ or internal part

steatorrhea

fat in the feces; frothy, foul-smelling fecal matter

Phimosis and Paraphimosis

foreskin not retractable. Prepuce too tight to retract/return from retracted position. disorders in which the foreskin is "too tight"

If a male client is uncircumcised, the glans of the penis is covered by the

foreskin. If the man has not been circumcised, a hood-like fold of skin called the foreskin or prepuce covers the glans.

An older adult client who is admitted to the hospital with acute confusion has urinary incontinence. The nurse can accurately document this as which type of incontinence?

functional Functional incontinence can result from impaired cognition such as that which occurs with acute confusion. The older adult client may also have problems with mobility. This can also be a factor in identifying the type of incontinence as functional. Overflow incontinence is related to neurological disorders or anatomic obstructions from pelvic organs or prostate enlargement limit bladder emptying until the bladder becomes over-distended. Stress incontinence results from an increase in intra-abdominal pressure such as that caused by laughing. Urge incontinence results from the inability to hold urine due to detrusor over-activity causing decreased contractility of the urethral sphincter or poor support of the bladder neck.

The corpora spongiosum extends distally to form the acorn-shaped

glans. The corpus spongiosum extends distally to form the acorn-shaped glans.

natal cleft

groove separating buttocks

A male client has a distinctive bulge in the right inguinal area when standing. What should the nurse suspect is occurring with this client?

hernia. A noticeable bulge in the inguinal area when standing strongly suggests that the male client has a hernia. Hypospadias is a displacement of the urinary meatus. Testicular torsion would be suspected if the scrotum were edematous and painful. An epidermoid cyst is a painless mobile mass in the scrotum. It would not be observed while the client is standing.

Losartan (Cozaar)

hypertension

The nurse notes that a client's abdominal skin is pale and taut. What should the nurse suspect is causing this finding?

Fluid accumulating in the abdominal cavity Pale taut skin may be seen with ascites which is significant abdominal swelling that indicates fluid accumulation in the abdominal cavity. Jaundice would be present if the liver is inflamed. Purple discoloration at the flank areas indicates bleeding within the abdominal wall. Dilated veins may be seen with obstruction of the inferior vena cava.

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?

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 new mother calls the clinic because she is concerned about her infant who is having a stool after each feeding. The nurse explains that this is a common occurrence because of what reflex?

Gastrocolic. Infants commonly produce stool after each feeding because of the gastrocolic reflex. Between 12 and 18 months of age, infants gradually achieve control of the external anal sphincter. The other options are distracters for the question.

A nurse is planning to palpate for a urethral discharge in a male client. Which technique would be best for the nurse to use?

Gently squeeze the glans between the thumb and index finger. To palpate for urethral discharge, the nurse would gently squeeze the glans between the thumb and index finger. Having the client hold the penis, observing the glans, or inspecting the scrotal skin would be inappropriate.

A nurse is planning to assess a male client for urethral discharge. Which technique would be best for the nurse to use?

Gently squeeze the glans between the thumb and index finger. To palpate for urethral discharge, the nurse would gently squeeze the glans between the thumb and index finger. Having the client hold the penis, observing the glans, or inspecting the scrotal skin would be insufficient because discharge in the urethra cannot be visualized.

The nurse is completing a health history on a patient reporting musculoskeletal pain. Which question(s) would be appropriate for the nurse to include in the interview? (Select all that apply.)

Have you experienced any previous injuries to your joints, do you exercise regularly, what type of job do you have, have you had any recent weight gain, what medications are you currently taking. Rationale:The nurse should ask about previous injuries to joints because the patient is reporting musculoskeletal pain. Assessing the patient's exercise level is important because regular exercise promotes flexibility, bone density, muscle tone, and strength. The nurse would ask about occupation because certain job-related activities can increase the risk of musculoskeletal problems. Recent weight gain could put stress on the musculoskeletal system. It is important to ask about medications because some medications can affect musculoskeletal function.

During a client's genitourinary exam, the nurse notes that the client's scrotum is enlarged and easily transilluminates. What should the nurse suspect?

Hydrocele. Swelling or masses that contain serous fluid, such as hydrocele or spermatocele, light up with a red glow with transillumination. Swellings or masses that are solid, or filled with blood, such as tumors, hernias, or varicocele, do not transilluminate.

During a scrotal exam, the nurse notes an enlarged scrotal sac that easily transilluminates. Which of the following would the nurse suspect?

Hydrocele. Swelling or masses that contain serous fluid, such as hydrocele or spermatocele, light up with a red glow with transillumination. Swellings or masses that are solid, or filled with blood, such as tumors, hernias, or varicocele, do not transilluminate.

hypertrophy vs hyperplasia

Hypertrophy: bigger cell (more cellular proteins. Hyperplasia: more number of cells.

Inspection of a client's penis reveals that the urethral meatus is located on the ventral side of the penis. The nurse documents this finding as which of the following?

Hypospadias. Hypospadias is a condition in which the urethral meatus is located underneath the glans or on the ventral side. Epispadias is condition in which the urethral meatus is located on top of the glans or on the dorsal side. Paraphimosis is a condition in which the foreskin is so tight that once retracted, it cannot be returned back over the glans. Phimosis occurs when the foreskin is so tight that it cannot be retracted.

The nurse is educating Mr. Russell on how to prevent falls. Which statement, if made by the patient, indicates that he understood the teaching?

I should press my call light when I want to get out of bed. Rationale:Mr. Russell has understood the teaching if he states he will use the call light if he wants to get out of bed. Mr. Russell should have non-skid socks on at all time while ambulating and should always use his walker—not just when feeling unsteady. He should keep the walker close to his bed rather than close to the door so that it is easily accessible.

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?

Irritable bowel syndrome

Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely?

Irritable bowel syndrome Although colon cancer should be a consideration, these symptoms are intermittent and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely, especially given that she is a young woman. This very common condition can be triggered by certain foods and stress.

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?

Irritable bowel syndrome. Explanation: Irritable bowel syndrome will cause loose bowel movements with cramps, but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely found in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse as well as certain foods.

A nurse determines that the liver span of an older adult male client measures 6 cm at the MCL. How would the nurse would interpret this finding?

It is a normal-sized liver. The normal liver span is 6 to 12 cm at the MCL and 4 to 8 cm at the MSL, so this is a normal finding. Liver size begins to decrease after age 50. If the measurement was greater than 12 cm, the client's liver would be enlarged. A decreased span suggests liver atrophy.

Nursing students are giving a class presentation on the digestive process. The students would identify villi as being present in what part of the GI tract?

Jejunum Absorption of nutrients takes place almost exclusively in the small intestine. In the first portion of the small intestine—the duodenum—pancreatic juices and bile are secreted into the chyme. This makes the nutrients in the chyme available for absorption by the many villi that line the walls of the remaining two portions of the small intestine: the jejunum and the ileum.

When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that a varicocele is present?

Palpable and tortuous veins. The presence of palpable and tortuous veins indicates varicocele. A beaded or thickened cord indicates infection or cysts. A smooth, nontender, and ropelike cord is a normal finding. In most men, one testicle hangs lower than the other in 65% of males, the left hangs lower than the right.

After positioning a 34-year-old client for examination of the anal region, the nurse notes a small opening above the gluteal crease that contains a tuft of hair. How should the nurse interpret this assessment finding?

The pilonidal cyst and sinus are usually benign, but can occasionally become infected or develop further sinuses. A pilonidal cyst is a congenital, and usually asymptomatic, tract that can become a problem if infection or sinus formation results. It alone does not indicate infection.

Pre-Simulation Quiz

...

pilonidal cyst or sinus

A cyst near or on the natal cleft of the buttocks that often contains hair and skin debris.

The peritoneum is a serous membrane that contains which of the following?

A parietal layer The peritoneum , mesentery, and muscles are also part of the abdominal cavity. The peritoneum is a serous membrane that covers and holds the organs in place. It contains a parietal layer that lines the walls of the abdomen and a visceral layer that coats the outer surface of the organs.

ARB

Angiotensin Receptor Blocker

The nurse would assess for positive Blumberg sign how?

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.

How should a nurse proceed with palpation of the anus to best facilitate the exam without causing the client undo discomfort?

Ask the client to bear down and place the lubricated finger on the anal opening. The nurse should lubricate the index finger of the gloved hand and ask the client to bear down. As the client bears down, place the pad of the index finger on the anal opening. When the sphincter relaxes, insert the finger with the pad facing down. Do not use the fingertip because this may cause the sphincter to tighten and this will cause pain when placed into the rectum. Spread the gluteal folds with the hands and attempt to visualize the anal opening is necessary if the client reports severe pain in order to see if there is a lesion present.

The nurse is assessing a client in the emergency department. The client was involved in a motor vehicle accident and is experiencing left upper abdominal pain. The nurse should intervene when another health care provider does which of the following?

Attempts to palpate the spleen If trauma to the spleen is suspected, the spleen should not be palpated. Palpation could cause the spleen to rupture and the nurse should intervene to prevent this from happening. The nurse would expect for the client to be placed in a cervical collar as the client was in a motor vehicle accident. The cervical collar should remain in place until the neck and spine are deemed stable. A spiral computerized tomography (CT) scan is expected to be ordered to rapidly help identify injuries sustained during the accident. The nurse should also expected blood to be drawn quickly from any site available to monitor the hemoglobin and hematocrit, as there is a need to check for internal bleeding.

thrombosed

Clotted--refers to a vessel that is affected by clotting.

The nurse is assessing a patient's joints. What should the nurse include in this assessment? (Select all that apply.)

Color, Symmetry, Size. Rationale:In an assessment of a patient's joints, the nurse should assess for size, shape, color, and symmetry. Reflexes and sensation should be included in a neurologic assessment.

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 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 concerned about his risk for developing testicular cancer. Which of the following should the nurse mention as a risk factor for this type of cancer?

Cryptorchidism. Cryptorchidism increases the risk of testicular cancer. Being uncircumcised increases the risk for cancer of the glans penis, but not testicular cancer. A sedentary lifestyle increases the risk for colorectal cancer, not testicular cancer. Smoking is not associated with an increased risk for testicular cancer.

The nurse is completing passive range-of-motion (ROM) exercises and bends the patient's foot so that the toes point upward. Which skeletal muscle movement has the nurse performed?

Dorsiflexion. Rationale:The skeletal muscle movement the nurse has performed is dorsiflexion. In plantar flexion, the toes point downward. Abduction is a movement away from the body, and adduction is a movement toward the body.

The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant?

Dullness Normal percussion findings include dullness over the liver in the RUQ and hollow tympanic notes in the LUQ over the gastric bubble. Hums and rubs are auscultatory sounds.

The nurse is describing various terms related to the male reproductive system. Which term would the nurse use to describe the discharge of semen from the penis?

Ejaculation. Ejaculation refers to the discharge of semen from the penis. Erection refers to the state in which the penis becomes elongated and rigid. Dilation of the penile arteries compresses the veins within the penis causing engorgement of blood within the tissue. Emission refers to the movement of sperm and their mixture with fluid forms the seminal vesicles and prostate gland into the urethra.

A nurse examines the external genitalia of a client and observes that the scrotum is enlarged, reddened, and swollen. On palpation, the epididymis is tender and the client complains of sudden pain. How should the nurse document this condition?

Epididymitis. The nurse should document this condition as epididymitis, which is an infection of the epididymis. In this condition, the scrotum appears enlarged, reddened, and swollen, and a tender epididymis is palpated. Cryptorchidism is a condition in which the scrotum appears underdeveloped and the testis cannot be palpated. It occurs when one or both testicles fail to descend into the scrotum. Orchitis is the inflammation of the testes, associated frequently with mumps; the scrotum appears enlarged and reddened. Hydrocele appears as a swelling in the scrotum and is usually painless.

A client presents to the health care clinic with reports of clay-colored stool. The nurse recognizes that this finding is most likely a result of which of the following?

Lack of bile pigment. Clay-colored stool results from the lack of bile pigment. Black stools may indicate gastrointestinal bleeding in this client who has not been receiving iron supplements or taking Pepto-Bismol. Yellow stool suggests increased fat content or steatorrhea. Cancer of the rectum or colon may be indicated by blood detected in the stool.

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?

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 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?

Listen with the bell of the stethoscope for vascular sounds

The nurse is reviewing Mr. Russell's medications. Which medication(s) would place Mr. Russell at a higher risk for falls? (Select all that apply.)

Losartan, metformin, Chlorthalidone. Rationale:Losartan (antihypertensive), metformin (antidiabetic), and chlorthalidone (diuretic) all place Mr. Russell at a higher risk for falls. Aspirin and the nicotine patch do not contribute to fall risk.

The nurse is presenting a program about sexually transmitted infections, including HIV, to a group of young men. The nurse would include who as the having the highest incidence of HIV infection in the United States?

Men having sex with men. Although transmission routes vary (male-to-male anal sex, intravenous drug use, heterosexual sex, mother-to-infant transmission, and other mechanisms of body fluid transfer), the highest incidence of HIV in the United States still occurs in men who have sex with men (MSM), followed by intravenous drug users.

A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation?

Right side-lying Having the client lie on the right side may facilitate splenic palpation by moving the spleen downward and forward. Alternatively, the client may be positioned supine.

The nurse is assessing the genitalia of an older adult client. What would the nurse document as a normal finding?

Testes hanging lower in the scrotum. In the older adult male, the testes hang lower in the scrotum, the penis becomes smaller, and pubic hair may be gray and sparse. The testes do not decrease in size with aging; however, they may decrease in size with long-term illness. Bulging in the inguinal area would be considered an abnormal finding associated with a hernia.

The nurse is teaching a group of student nurses in the lab about male anatomical differences and assessment. Which of the following should be included in the teaching?

The assessment should be completed in a warm room. Scrotal examination should occur in a warm room as the sac rises towards the body in colder temperatures. The arms do not need to be raised for the assessment. The client should be standing or lying comfortably. The skin on the scrotal sac should be loose and wrinkled. If the client is circumcised, the prepuce should be gently retracted for inspection. The prepuce should not be forcibly retracted.

Benign prostatic hyperplasia (BPH)

benign growth of cells within the prostate gland

para

beside

varicocele

enlarged, dilated veins near the testicle. enlarged veins of the spermatic cord.

prone position

lying on abdomen, facing downward

The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should

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 client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment?

place a small pillow under the client's knees A small pillow placed under the knees relaxes the abdominal musculature. The abdominal assessment should not be performed with the head of the bed raised to a 30-degree angle or sitting with the legs dangling. Removing a pillow from behind the client's head will make the abdominal muscles more tense.

To palpate the spleen of an adult client, the nurse should

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.

A male client comes to the clinic reporting a painless red, oval ulceration on his penis that had started out as a small silvery-white bump. Which of the following disorders would the nurse suspect?

primary sign of syphilis. Syphilis presents with a small silvery-white papule that is painless and that later develops into a red oval ulceration that is also painless. Human immunodeficiency virus (HIV) presents with flu symptoms that resolve; the client may not experience any other symptoms for a long period of time (latent period) before developing symptoms leading to autoimmune disorder (AIDS) if not treated. Herpes progenitalis presents as painful clusters of pustules on the genitals. Phimosis is the inability to retract the foreskin.

To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should

raise the client's right leg from the hip. Assess for psoas sign by asking the client to lie on the left side. Hyperextend the right leg of the client.

atrial fibrillation

rapid, random, ineffective contractions of the atrium

tunica vaginalis testis

serous membrane that surrounds the front and sides of the testicle.

flank

side of the body between the ribs and ilium

Syphilitic chancre

skin lesion associated with primary syphilis

straie

stretch marks made in the collagen fibers of the dermis layer.

epididymis

A long, coiled duct on the outside of the testis in which sperm mature.

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

Assess the client for other signs and symptoms of liver disease. Ascites and dilated surface arterioles and capillaries with a central star (spider angioma) may be seen with liver disease. These findings are less likely to result from excess fluid volume, impaired nutrition, or hematologic problems.

When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that an infection or cysts are present?

Beaded or thickened cord. A beaded or thickened cord indicates infection or cysts. The presence of palpable and tortuous veins indicates varicocele. A smooth, nontender, and rope-like cord is a normal finding. In most men, one testicle hangs lower than the other; in 65% of males, the left hangs lower than the right.

ventral side

belly side

Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect?

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.

The nurse educates the client that what condition may be associated with a varicocele?

Infertility. Infertility is may be associated with a varicocele. Klinefelter's syndrome is related to small testes. Circulatory obstruction is associated with orchitis. Ischemia may be occur with torsion.

Why is the appearance of urine important to evaluate during an abdominal examination?

Dark urine may be from dehydration Cloudy urine may indicate UTI. Sediment may indicate kidney disease. Blood can be caused from renal injury, renal disease, or trauma to a catheter. Dark urine may be from dehydration.

Older adults often have trouble with swallowing. What might cause this?

Decreased saliva production In older adults, production of saliva and stomach acid is reduced and gastric motility and peristalsis slow. These changes can lead to difficulties with swallowing, absorption, and digestion.

Chlorthalidone (Hygroton)

Diuretic

Which of the following people need to be vaccinated for hepatitis A and B?

Food-service workers Hepatitis A and B immunizations are recommended for all infants; people whose work may expose them to blood, body fluids, or unsanitary conditions (i.e., health care, food services, sex workers); and those traveling to parts of the world where these illnesses are prevalent.

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?

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.

The nurse is assessing a patient's range of motion and notes a limitation in the movement of the elbow joint. Which tool would the nurse use to measure the degree of movement in the joint?

Goniometer. Rationale:The nurse would assess range of motion using a goniometer, which measures the degree of movement in a joint. The tape measure, metric ruler, and reflex hammer would not be used to measure the degree of movement.

A male client is complaining of pain with urination, rectal pain and urethral discharge. The nurse suspects this is what?

Gonorrhea. Gonorrhea symptoms include pain with urination, rectal pain and urethral discharge. Chlamydia is generally asymptomatic. Scabies is associated with papules, vesicles, pustules and itching. Syphilis has five stages but is exhibited by a genital lesion.

HAI

Healthcare-associated/acquired infection.

An adolescent present at the free clinic with a collection of fluid in the tunica vaginalis of the testes. The nurse knows that the term that defines this condition is what?

Hydrocele. A hydrocele refers to a collection of fluid in the tunica vaginalis of the testes. Cryptorchidism is the most common congenital defect in males; characterized by failure of one or both of the testes to descend into the scrotum. Orchitis is an inflammation of the testes (testicular congestion) caused by pyogenic, viral, spirochetal, parasitic, traumatic, chemical, or unknown factors. Prostatism is an obstructive and irritative symptom complex that includes increased frequency and hesitancy in starting urination, a decrease in the volume and force of the urinary stream, acute urinary retention, and recurrent urinary tract infections.

A client presents to the health care clinic with reports of yellow stool. Which condition should the nurse most suspect?

Increased fat content. Yellow stool suggests increased fat content or steatorrhea. Black stools may indicate gastrointestinal bleeding in this client who has not been receiving iron supplements or taking Pepto-Bismol. Clay-colored stool results from the lack of bile pigment. Cancer of the rectum or colon may be indicated by blood detected in the stool.

You are assessing a client for acute cholecystitis. What sign would you assess for?

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.

While assessing the scrotum of an adult client, the nurse notes thin and rugated scrotal skin with little hair dispersion. The nurse interprets this finding as which of the following?

Normal findings. Scrotal skin is normally thin and rugated with little hair. Inflammation of the penis and scrotum may be seen in Reiter's syndrome. Absence or scarcity of pubic hair may suggest chemotherapy. A yellow urethral discharge is usually seen with gonorrhea.

A male client is receiving chemotherapy for the treatment of cancer. Which finding should the nurse anticipate during examination of the client's genitalia?

Sparse pubic hair. Hardness along the ventral surface may indicate a urethral stricture. Sparse pubic hair may be seen in clients receiving chemotherapy or in an older adult client. Tenderness on palpation may indicate inflammation or infection. Cyanosis to the glans is not a consequence of chemotherapy.

The nurse is preparing to perform an abdominal assessment for a client. What would be most appropriate for the nurse to do to promote relaxation of the client's abdominal muscles?

Place a pillow under both of the client's knees. Placing a pillow under the client's knees provides slight flexion, which helps to relax the abdominal muscles. Having the client breathe through the mouth and take slow deep breaths promotes overall relaxation. A warm blanket prevents chilling but does not promote relaxation of the abdominal muscles. The nurse would inform the client that painful areas will be assessed last and would assure the client that they will be forewarned about examining these areas.

During a focused genital assessment of an older adult client, the nurse observes a skin tag that protrudes through the rectum. How should the nurse document this finding?

a previously thrombosed hemorrhoid. A previously thrombosed hemorrhoid appears as a skin tag. Redness, itchiness, and signs of scratching could indicate pinworm or fungi; the client is not exhibiting these signs or symptoms. A perianal abscess presents as hardened and red. An external hemorrhoid is itchy, painful, and swollen.

dorsal side

back side

Somatic sensory nerves

carry impulses from body surface to the CNS

phim/o

closed tight

Paraphimosis

condition in which a retracted prepuce cannot be pulled forward to cover the glans

epispadias

congenital defect in which the urinary meatus is located on the upper surface of the penis

The nurse is taking the health history of a client who takes a calcium channel blocking medication for hypertension. The client reports a sensation of incomplete evacuation when having a bowel movement about three times per week. For which problem should the nurse further assess the client?

constipation Clients with constipation have 25% or more defecations with either straining or a sensation of incomplete evacuation per week. Sigmoid colon lesions are characterized by thin, pencil-like stools due to an obstructing "apple-core" lesion in this area of the bowel. A clostridium difficile infection is characterized by diarrhea and should be suspected if the client has recently been hospitalized. Pancreatic insufficiency should be further investigated if the client reports having oily or greasy stools.

DRE

digital rectal examination

pathy

disease condition

Analgesics

drugs that relieve pain

The nurse is caring for Mr. Russell, who is recovering from a stroke and has mild left-sided hemiplegia. What would the nurse include in the plan of care? (Select all that apply.)

encourage the pt to set realistic short term goals, Perform passive range of motion exercises. Rationale:The nurse includes passive range-of-motion exercises in the plan of care and should encourage the patient to set realistic, short-term goals. The patient should call for assistance when ambulating rather than try to maintain independence. It is important for the patient to use assistive devices as long as necessary. The nurse should cluster care activities to allow the patient to rest rather than spread them throughout the day.

varicocele

enlarged veins of the spermatic cord

adeno

gland, glandular

inguinal area

groin

hypertrophy

increase in cell size

While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tinkling sounds throughout the distended abdomen. The nurse should refer the client to a health care provider for possible

intestinal obstruction. Obstruction often presents with high-pitched tinkling sounds above the obstruction, in combination with distended abdomen; abdominal cramping is often present as well. Gastroenteritis may present with hyperactive bowel sounds that include tinkling, rushing, and high-pitched sounds and diarrhea is typical, but a distended abdomen is not typical. Cirrhosis of the liver may present with venous hum.

IV

intravenous

right costal margin

is over the liver and gallbladder

left costal margin

is over the stomach and spleen

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the

left upper quadrant.

peptic ulcer

open sore in the lining of the stomach or duodenum

inguinal ring

openings in abdominal muscles thru which testes descend

Spermatocele (Epididymal Cyst)

painless, fluid-filled cyst in the long, tightly coiled tube that lies above and behind each testicle

A nurse observes that the mucosa of the rectum and the rectal wall of a female client protrudes out through the anal opening. It appears as a red, doughnut-like mass with radiating folds. How should the nurse document this condition of the rectum?

prolapse. The nurse should document this condition as rectal prolapse. Soft structures like nodules that may be present in the muscular anal ring are called rectal polyps. They are rather common and occur in varying size and number. If cancer metastasizes to the peritoneal cavity, it may be felt as a nodular, hard, shelf-like structure called rectal shelf that protrudes onto the anterior surface of the rectum in the area of the rectouterine pouch in women. Rectal cancer may feel like a firm nodule, an ulcerated nodule with rolled edges, or, as it grows, a large, irregularly shaped, fixed, hard nodule.

Anticoagulant drugs

reduce the likelihood of blood clotting

The colon originates in this abdominal area: the

right lower quadrant The colon, or large intestine, has a wider diameter than the small intestine (approximately 6.0 cm) and is approximately 1.4 m long. It originates in the RLQ, where it attaches to the small intestine at the ileocecal valve.

To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's

right lower quadrant.

Where is the liver located?

right upper quadrant

Hydrocele

sac of clear fluid in the scrotum

-spadias

slit, fissure

The nurse identifies a cheesy white material that has accumulated under a male client's foreskin of the penis. What does this finding suggest to the nurse?

smegma. A cheesy white material may accumulate under the foreskin of a client. This is smegma and is considered normal. Balanitis refers to inflammation of the glans, not the expected secretions of the glans that cause smegma to accumulate. The accumulation of secretions from the glans (smegma) does not indicate that a sexually transmitted infection is present. Hypospadias refers to a congenital condition that involves ventral displacement of the meatus on the penis.

cryptorchidism

state of hidden testes/ undescended testes.

cryptorchidism

state of hidden testes/ undescended.

Mumps

swelling

The nurse is performing blunt percussion of a client's kidneys. For what abnormal finding is the nurse primarily assessing?

tenderness This form of percussion is done not to elicit sound but rather to determine the presence of tenderness that may indicate inflammation or infection. Therefore, the nurse would not perform blunt percussion to assess for dullness, tympany, or hyperresonance.

Semi-Fowler's Position

the head of the bed is raised 30 degrees

taut

tight

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should

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.

afebrile

without fever

The nurse is assessing flexion in Mr. Russell's hip. What instructions would the nurse give to Mr. Russell to complete this assessment?

"Bend your knee to your chest, and then pull it against your abdomen." Rationale:To assess flexion of the hip, the nurse would instruct Mr. Russell to bend his knee to his chest and then pull it against his abdomen. Instructing the patient to lie face down and then bend the knee and lift it up assesses extension. Asking the patient to lie flat and then move the lower leg away from the midline assesses abduction. Instructing the patient to lie flat and then bend the knee and move the lower leg toward the midline assesses adduction.

The nurse is talking with parents of a newborn male about circumcision. The nurse should intervene when one of the parents makes which of the following statements?

"Circumcision is recommended by the American Academy of Pediatrics." The American Academy of Pediatrics does not recommend routine circumcision for newborn males. The decision to circumcise a newborn male should be made by the family and not decided by the medical team. Research indicates that circumcision lowers the risk of urinary tract infections and ulcerative sexually transmitted infections such as gonorrhoea.

A 49-year-old woman has visited the clinic with complaints of excessive flatus and bloating, symptoms that are causing her both discomfort and embarrassment. Which of the following questions should the nurse ask the client during assessment of the health problem?

"Do you find that any particular foods, like dairy, make the problem worse?" A deficiency in lactase often manifests as excessive gas and bloating. A personal or family history of colon cancer, indigestion, or weight changes would be less likely to relate to the client's immediate complaint, though each problem should be assessed for in the course of the assessment.

A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem?

"Do you take painkillers like aspirin on a regular basis?" Regular use of nonsteroidal anti-inflammatory medications (NSAIDs) is implicated in the incidence of PUD. Stress is a contributing, but not causative, factor. Vitamin supplements and a high-fat diet are not considered to be causative factors.

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?

"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.

The nurse is reviewing lifestyle changes with a client who is attempting to reduce the risk for colon and prostate cancer. Which statement by the client requires further follow-up by the nurse?

"I am on a high-protein diet that includes red meats." The statement, "I am on a high-protein diet that includes red meats," requires further follow-up by the nurse, because a diet high in red meat increases the risk for prostate cancer. The statements, "I have been increasing the fiber in my diet," "I have started to finally get my weight under control," and "I am now abstaining from alcohol," all reflect lifestyle changes that reduce the risk of prostate and colon cancer.

After teaching a client about measures to reduce his risk for colon cancer, the nurse determines that the teaching was successful when the client states which of the following?

"I should eat a half-cup of raisins every day." Raisins contain tartaric acid and fiber, which reduce bile acids and speed food through the gastrointestinal system, thus decreasing constipation and the risk for cancer. A diet high in animal proteins such as red meats is a risk factor for colon cancer; therefore the client should eat a diet that is low in animal protein. The client also should increase his fiber intake, including fruits and vegetables such as green leafy vegetables.

A 17-year-old male client expresses concern about feeling lumps on his testicles. What response by the nurse would best address the client's concerns?

"The normal testicle contains internal structures that cause lumps on the surface." Each normal testicle has a small, coiled tube (epididymis) that can feel like a small bump on the upper or middle outer side of the testicle. Normal testicles also have blood vessels, supporting tissues, and tubes that carry sperm. Asking for the client's opinion on whether or not the testicles are malformed does not yield assessment data or address the client's need for more information. Telling the client not to worry and describing the testicles as normal provides incomplete information to the client. Because the client's given concern is not regarding sexual performance, this is not a statement that the nurse should use; additionally, describing the testicles as lumpy is an inaccurate way to refer to an expected assessment finding.

A male client suffers from urinary retention. Which instructions are best to teach the client?

"Try voiding, then resting a few minutes, before going again." A client suffering from urinary retention can be instructed to try double voiding to completely empty the bladder. Retention of urine can lead to stasis and infection. Drinking more water and frequent toileting does not relieve the cause of urinary retention. If double voiding does not help, the client can be referred to a urologist.

stricture

(n.) a limitation or restriction; a criticism; (medicine) a narrowing of a passage in the body.

atrophy

(n.) the wasting away of a body organ or tissue; any progressive decline or failure; (v.) to waste away.

The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location?

- Deep epigastrium to the left of midline. To palpate the aorta, the nurse would palpate deeply in the epigastrium, slightly to the left of midline. The pregnant uterus may be palpated above the level of the symphysis pubis in the midline. A filled bladder may be palpated in the abdomen above the symphysis pubis.

Prostate enlargement is common in older men. The nurse should be aware of what signs and symptoms when interviewing an older male client? Select all that apply.

- Dribbling. - Straining to urinate. - Sensation of residual urine. The location of the prostate gland can affect urine flow if the prostate becomes enlarged. The following are the signs of partial prostate obstruction: recurrent acute UTIs, the sensation of residual urine, decreased caliber of the urine stream, hesitancy, straining, and terminal dribbling. Chronic kidney infection and a nonsubsiding erection represent other medical problems unrelated to the prostate.

Which assessment questions are appropriate for people of Native American descent? Select all that apply.

- Have you had liver disease, gallbladder disease, or pancreatitis? - Do you have diabetes? - Have you ever had yellow skin or yellow eyes? - Do you drink alcohol? If so, how much and how often? Alcoholism, diabetes, liver and gallbladder diseases, and pancreatitis are more prevalent in the Native American population. Yellow skin or eyes can accompany liver diseases. Gastric cancer has increased incidence in Asian populations.

A mother is worried about her teenage child's weight. The teenager weighs 80 kg (176 lbs). What can the nurse teach the mother about her child's eating habits? Select all that apply.

- Supply only healthy foods in the house. - Educate the family about the poor nutritional value of fast food. - Supply nutritional information to the child. Teenagers assume control of their eating and may reject family values. The only control parents may have is over what food is in the house, although they should still supply nutritional information to their children. Fast food is high in fat, calories, and salt and has little fiber. Teenagers require 2,200 calories per day.

The nurse is assessing an adult client with severe abdominal pain and asks the client if they have had any prior surgeries. The client states that she had a hysterectomy 20 years ago. Why is this information relevant? Select all that apply.

- The information shows increased risk for adhesions - The information shows increased risk for adhesions - The information shows increased risk for obstructions Teenagers assume control of their eating and may reject family values. The only control parents may have is over what food is in the house, although they should still supply nutritional information to their children. Fast food is high in fat, calories, and salt and has little fiber. Moderately active teenage girls require an average of 2,200 calories per day. Moderately active teenage boys require an average of 2,800 calories a day

Chapter 20: Abdominal Assessment

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Chapter 23: Male Genitalia and Rectum

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Health Assessment Case: Vernon Russell

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Post-Simulation Quiz

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The nurse is assessing a 12-year-old boy and finds the following: sparse growth of pubic hair, beginning penile enlargement, and beginning textural changes on the scrotum. The nurse would document which Tanner stage?

2. Tanner stage 2 for males consists of sparse growth and slightly curly pubic hair, slight or no enlargement of the penis, and both the testes and scrotum larger, reddened, and beginning to exhibit textural changes. Tanner stage 1 is characterized by no pubic hair and a penis, testes, and scrotum of the same size and proportion as in childhood. Tanner stage 3 is characterized by darker, coarse curly sparse pubic hair over the symphysis pubis, a larger and longer penis, and continued enlargement of the testes and scrotum. Tanner stage 4 is characterized by coarse, curly pubic hair that does not extend to the medial thighs, increased penile length and width with development of the glans, and continued enlargement of the testes and scrotum with a darkening of the scrotal skin.

The nurse is assessing the muscle strength in Mr. Russell's left hand and notes active motion against some resistance. How would the nurse document this finding?

4. Rationale:The nurse would document this finding as 4, slight weakness. Active motion against full resistance is 5, or normal strength. Active motion against gravity would be charted as 3, average weakness. Finally, a finding of 2 is passive range of motion (ROM) or poor ROM.

Which of the following male clients is most in need of immediate medical treatment? A 30-year-old who presents with palpable nodules in his left testis A 15-year-old boy who has been brought in by his mother for assessment of his severely painful testes that are retracted upward A 70-year-old retiree whose intestines are palpable in his scrotum A 22-year-old student who has presented with a cluster of painful lesions on the shaft of his penis

A 15-year-old boy who has been brought in by his mother for assessment of his severely painful testes that are retracted upward. Torsion of the spermatic cord, as exemplified by painful retraction of the testes in an adolescent, constitutes a medical emergency. Herpes, inguinal hernias, and testicular tumors necessitate treatment but are not medical emergencies.

Tympany

A bell-like noise when tapping the abdomen. high-pitched, musical, drumlike percussion note heard when percussing over the stomach and intestine

Which of the following would lead the nurse to suspect a hydrocele versus other causes of scrotal swelling?

A positive transillumination test. A cystic structure will often transilluminate well. While a transilluminator head for the battery handle is ideal, it is possible to use an otoscope to transilluminate the scrotum. The examiner should be able to get above the mass on palpation, and bowel sounds should not be present. If they are, it should lead the examiner to consider an inguinal hernia. Scrotal edema involves thickened skin, which can be measured by gently pinching a section of the scrotum itself.

A tender painful swelling of the scrotum should suggest which of the following?

A tender, painful, swelling of the scrotum can be a medical emergency. All of these conditions should be considered as well as acute orchitis.

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?

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?

Absent

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?

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 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 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.

A 22-year-old law student comes to the office complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs, but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank around 14 drinks. Examination shows a young man appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending. What etiology of abdominal pain is most likely causing his symptoms?

Acute pancreatitis Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates into the back. There is often a history of long-standing gallbladder disease or recent alcohol ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump inhibitors can also cause pancreatitis in people without these other risk factors. Treatment includes hydration, pain management, and bowel rest.

The client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for?

Acute pancreatitis With acute pancreatitis, epigastric pain may radiate to the back or other parts of the abdomen; it may be poorly localized.

A nurse is palpating the prostate of a client and finds it to be swollen, tender, firm, and warm to the touch. Which condition should the nurse most suspect?

Acute prostatitis. The prostate is normally nontender and rubbery. A swollen and tender prostate that is firm and warm to the touch may indicate acute prostatitis. An enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests benign prostatic hypertrophy. A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest cancer. Hydrocele is a painless swelling of the scrotum.

Which of the following groups has the highest incidence of prostate cancer?

African American men. African American men have the highest incidence of prostate cancer—two to three times higher than Caucasian men.

Which finding obtained during the abdominal assessment in an older adult client should prompt the nurse to perform an additional assessment to determine the cause?

An enlarged liver felt during palpation The liver normally decreases in size after age 50 years. An enlarged liver needs further assessment. Appetite decreases with age due to altered metabolism, decreased taste sensation, decreased mobility, and possibly depression. Tympany is a normal finding over the stomach. The fluid wave test should be negative unless fluid (ascites) is present in the abdomen.

Which of the following would the nurse most likely document when noting a small opening in the skin surrounding the anal opening?

Anorectal fistula. An anorectal fistula is observed as a small round opening in the skin that surrounds the anal opening. Pinworm infection would be noted by redness and excoriation from scratching the area. Trauma would be noted by splits in the skin tissue of the anal canal, often with a swollen skin tag below the fissure on the anal margin. Perianal abscess would be noted as a cavity of pus around the anal opening.

Metformin (Glucophage)

Antidiabetic

Where in the digestive tract is most of the water absorbed?

Any food particles not absorbed by the small intestine pass into the large intestine, where a few electrolytes and water are further absorbed.

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what?

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.

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?

Appendicitis 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 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.

A 60-year-old coach comes to the clinic complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream, and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s, and the client's father is currently in his 80s with high blood pressure and arthritis. Examination reveals a mildly obese alert and cooperative man. His blood pressure is 130/70 with a heart rate of 80. He is afebrile, and his cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove. An analysis of the urine shows no red blood cells, white blood cells, or bacteria. What disorder of the anus, rectum, or prostate is most likely?

Benign prostatic hyperplasia (BPH). BPH becomes more prevalent during the fifth decade and is often associated with hesitancy in starting a stream, decreased strength of stream, nocturia, and leaking of urine. On examination an enlarged, symmetrical, firm prostate is palpated. The anterior lobe cannot be felt. These clients may also develop UTIs secondary to their obstruction.

The nurse is palpating the prostate of a 55-year-old client and finds it to be enlarged, smooth, firm, and slightly elastic, without a median sulcus. Which condition should the nurse most suspect?

Benign prostatic hypertrophy The prostate is normally nontender and rubbery. A swollen and tender prostate may indicate acute prostatitis. An enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests benign prostatic hypertrophy. This condition is common in men older than 50 years. A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest cancer. Hydrocele is a painless swelling of the scrotum.

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?

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.

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. Normal bowel sounds consist of clicks and gurgles that occur at an estimated frequency of 5 to 34 per minute. The nurse should document that the bowel sounds are normal. Twenty bowel sounds in a minute is not hyperactive, hypoactive, or inconsistent.

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 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.

The nurse is completing passive range of motion on Mr. Russell. What movements would the nurse expect to complete at the elbow joint?

Flexion, extension, supination, pronation. Rationale:At the elbow joint, the nurse would expect to find flexion, extension, supination, and pronation of the forearm.

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 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.

A nurse examines the external genitalia of a client and observes that the scrotum is underdeveloped and the testis cannot be palpated. How should the nurse document this condition?

Cryptorchidism. The nurse should document this condition as cryptorchidism, a condition in which the scrotum appears underdeveloped and the testis cannot be palpated. Cryptorchidism is the failure of one or both testicles to descend into the scrotum. Orchitis is the inflammation of the testes, associated frequently with mumps; the scrotum appears enlarged and reddened. Epididymitis is an infection of the epididymis; the scrotum appears enlarged, reddened, and swollen, and a tender epididymis is palpated. Hydrocele appears as a swelling in the scrotum and is usually painless.

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?

Decreased activity of protective bacteria in the urinary tract Older adult clients are prone to urinary tract infections because the activity of protective bacteria in the urinary tract declines with age. It is not established that older adults have poorer hydration or nutrition than younger adults. A higher fat-to-lean muscle ratio would not affect risk for urinary tract infections.

The nurse is educating Mr. Russell on the effects of prolonged immobility. What physiologic change(s) would the nurse describe to Mr. Russell? (Select all that apply.)

Decreased muscle protein synthesis, increased muscle catabolism, decreased muscle mass, and bone demineralization. Rationale:Decreased muscle protein synthesis, increased muscle catabolism, decreased muscle mass, and bone demineralization are physiologic changes that result from prolonged immobility. Increased respiratory effort would not be a physiologic change related to prolonged bed rest.

The nurse is preparing to assess the size of the aorta. The nurse would palpate at which location?

Deep epigastrium to the left of midline To palpate the aorta, the nurse would palpate deeply in the epigastrium, slightly to the left of midline. The pregnant uterus may be palpated above the level of the symphysis pubis in the midline. A filled bladder may be palpated in the abdomen above the symphysis pubis.

A client complains of scrotal pain, and the nurse elicits a positive Prehn sign with relief of the pain. The nurse suspects which of the following?

Epididymitis. Passive elevation of the testes with relief of scrotal pain is a positive Prehn's sign indicating epididymitis. Painless nodules may indicate a scrotal mass or tumor. Tenderness and swelling may indicate a strangulated hernia. Palpable tortuous veins suggest a varicocele.

Which additional health history question related to the abdominal system is appropriate for people of African American decent?

Do you or your parents have sickle cell disease or trait? Sickle cell anemia has an autosomal recessive inheritance pattern and is most common among African Americans. Incidence of gastric and primary liver cancers is increased in Asians. Inflammatory bowel diseases and symptoms of heartburn, indigestion, anorexia, or unplanned weight loss are appropriate questions for clients of all ethnicities.

During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate?

Document the position of the liver. The liver is located below the diaphragm in the right upper quadrant of the abdomen, extending just below the right costal margin, where it may be palpated. The findings are considered normal and the client would not need a referral for medical follow-up. The exam detects the liver, not the spleen, which would be on the left side. There are no data to support the need for assessing the client's urinary output.

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?

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 nurse examines the anal area of a client and observes the presence of a varicose vein. How should the nurse document this finding?

External hemorrhoid. Hemorrhoids are usually painless papules caused by varicose veins, either external or internal. If the hemorrhoid becomes thrombosed is can become painful and swollen. A perianal abscess is a cavity of pus caused by infection in the skin around the anal opening. An anal fissure is a split in the tissue of the anal canal caused by trauma. An anorectal fistula is a small, round opening in the skin that surrounds the anal opening. It suggests an inflammatory tract from the anus or rectum out to the skin.

When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?

Family history; dietary habits. Poor diet and a family history are both identified as risk factors for colorectal cancer. These aspects of the history would supersede the client's surgical history and social patterns.

A male in college presents to the health clinic with complaints of fever, malaise, and swelling of the sides of the neck. A blood test confirms the presence of mumps. The nurse should educate the client to report which changes of his genitalia to the health care provider?

Feelings of heaviness and pain in the scrotum. Mumps may cause the onset of orchitis in males, which presents as a heaviness and swelling of the scrotum. The other symptoms listed are not associated with mumps, but with other conditions.

An Advanced Practice Nurse is preparing to do a rectal examination on a 77-year-old client. The client complains of pain as soon as the examination begins. What might this client have?

Fissures. Anorectal fissure is a rip in the anal mucosa; it can occur midline or posterior or anterior to the anus. Usually, a fissure is caused by the passage of large hard stool. On observation, a sentinel skin tag may be seen at the lower end of the fissure. Ulcerations may appear at the site. The client has bleeding, pain, and itching. Because the internal sphincter is spastic, anesthesia of the site is necessary for examination.

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?

Flex the client's legs by placing a pillow under the knees. The nurse should flex the client's legs by placing a pillow under the knees. This helps the abdominal muscles to relax and facilitates proper assessment. Raising the client's arms above the head or folding them behind the head may tense the abdominal muscles. Placing a pillow under the client's head or providing privacy does not help in relaxing the abdominal muscles; however, these measures will provide comfort and relaxation to the client.

What documentation in a client's history should a nurse recognize as an indication that the client has a normal prostate?

Heart-shaped, smooth, with two distinct lobes. The normal prostate should be nontender and rubbery. Two lobes are divided by a median sulcus. The lobes are smooth, 2.5 cm long, and heart-shaped.

When assessing the rectum, the nurse observes what appear to be engorged areas near the rectal opening. The nurse would most likely document this finding as which of the following?

Hemorrhoids. Hemorrhoids are veins that are engorged with blood. Anal crypts are recessed areas between the columns of Morgagni within the anal canal. The rectovesical pouch is the area where the peritoneum that lines the upper two-thirds of the anterior rectum dips down enough so that it can be palpated. Fibroids are benign tumors occurring in the uterus.

A daycare worker presents to the office with jaundice. She denies IV drug use, blood transfusion, and travel, and has not been sexually active for the past 10 months. Which type of hepatitis is most likely?

Hepatitis A The lack of blood and body fluid contact makes hepatitis B, C, and D unlikely. If she regularly changes the diapers of the children in her care she is at risk for hepatitis A. Vaccine against hepatitis A is recommended for daycare workers.

The nurse is using the Morse Fall Scale to determine Mr. Russell's fall risk. What variable(s) will the nurse assess by using this tool? (Select all that apply.)

History of falls, presence of IV, secondary diagnosis. Rationale:The Morse Fall Scale is widely used in hospital and long-term care settings and is used to assess six variables that put patients at a higher risk for falls. These include the following: history of falls, secondary diagnosis, ambulatory aid, IV or IV access, gait, and mental status. Although advanced age and female gender place a patient at risk for falls, they are not included in the Morse Fall Scale.

A 68-year-old man comes to the clinic reporting that he is having difficulty obtaining an erection. When reviewing the client's history what might the nurse note that contributes to impotence?

History of hypertension. Past history of infection, lack of exercise, and use of vitamins do not contribute to impotence. Vascular problems cause about half the cases of impotence in men older than 50 years.

A teenage male client comes to the ED with severe left testicular pain and vomiting. Elevation of his left testicle does not lessen the pain. What could these symptoms indicate for this client?

Left testicular torsion. Signs of testicular torsion include acute pain that is not relieved by elevating the testicle, nausea, and vomiting. Epididymitis usually presents in adult males. The client presents with unilateral pain to one testis, but fever, dysuria, and possibly urethral discharge. Hydrocele is the accumulation of fluid around a testicle. This condition usually presents as a non-tender and soft testicle. Often testicular cancer presents lump or swelling, which may or may not be painful. The condition could also present with pain in the abdomen or low back.

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 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.

A nurse auscultates for bowels sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after one minute. What is an appropriate action by the nurse?

Listen for a total of five (5) minutes 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.

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Listen for five minutes before documenting an absence of bowel sounds. The nurse must listen for at least 5 minutes before determining that no bowel sounds are present and that the bowels are silent. This constitutes a medical emergency, and prompt referral is necessary. The nurse does not perform percussion and palpation in an effort to stimulate peristalsis.

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?

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.

Palpation of a male client's urethra produces a yellowish-white discharge. What is the nurse's best action?

Obtain a sample of the discharge for culture. Any urethral discharge should be cultured. A urine sample may be indicated, but this is not always the case. Repeating palpation of the urethra after voiding will not add meaningful data. The presence of discharge does not create a direct indication for scrotal and testicular palpation, although these actions are part of the overall genitourinary assessment.

Prehn sign

Pain relieved upon elevation of testicle when patient is supine (Positive test). negative in testicular torsion positive in epididymitis ~ elevation of the testicle relieves pain.

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?

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.

During the physical examination of the genitalia for an uncircumcised client, the nurse asks the client to retract the foreskin of the penis. The nurse observes that the foreskin is tight and cannot be retracted. How should the nurse document this condition?

Phimosis. This condition should be documented as phimosis; wherein, the client's foreskin is so tight that it cannot be retracted. A foreskin that once retracted and can not be returned to cover the glans is called paraphimosis. Epispadias is the displacement of the urinary meatus to the dorsal surface of the penis. Hypospadias is the displacement of the urinary meatus to the ventral surface of the penis.

When performing the physical assessment of a client, the nurse notes the presence of a small cyst that contains hair, which is located midline in the sacrococcygeal area and has a palpable sinus tract. How should the nurse document this finding?

Pilonidal cyst. A pilonidal cyst is a congenital disorder characterized by a small dimple or cyst/sinus that contains hair. External hemorrhoids are usually painless papules below the anorectal junction, caused by varicose veins. Anal fissures are splits in the tissue of the anal canal caused by trauma. Perianal abscess is a cavity of pus, caused by infection in the skin around the anal opening.

A nurse is a preparing to assess a male client's anus and rectum. How should the nurse best prepare the client for this assessment?

Position the client in a left side-lying position. The most frequently used position for inspection and palpation of the anus, rectum, and prostate is the left lateral position. This position allows adequate inspection and palpation of the anus, rectum, and prostate (in men) and is usually more comfortable for the client. Pain control should not be necessary. Some men may be anxious or fearful during this exam, but the nurse would not normally raise this possibility unless he or she had reason to believe that the client felt this way.

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. How would the nurse document this finding?

Positive Rovsing's sign Findings indicating referred rebound tenderness constitute 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.

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?

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.

A client comes to the Emergency Department complaining of sudden sharp testicular pain. Further examination reveals torsion of the spermatic cord. Which of the following would the nurse expect to do next?

Prepare the client for surgery. For the client with torsion, immediate surgery is necessary to prevent atrophy of the spermatic cord and preserve fertility. Analgesics would be given preoperatively. Postoperatively, a scrotal support is applied and dressings are inspected for drainage. Circumcision is done to relieve phimosis or paraphimosis.

On inspecting a client's external genitalia, a nurse notes that he is uncircumcised. This means that which of the following covers the glans of the penis?

Prepuce. If the man has not been circumcised, a hood-like fold of skin called the foreskin, or prepuce, covers the glans. In the center of the corpus spongiosum is the urethra, which travels through the shaft and opens as a slit at the tip of the glans as the urethral meatus. The shaft of the penis is composed of three cylindrical masses of vascular erectile tissue that are bound together by fibrous tissue—two corpora cavernosa on the dorsal side and the corpus spongiosum on the ventral side.

On palpation of a client's prostate, a nurse detects hard, fixed, and irregular nodules on the prostate. Which condition should the nurse most suspect in this client?

Prostate cancer. The prostate is normally nontender and rubbery. A swollen and tender prostate may indicate acute prostatitis. An enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests benign prostatic hypertrophy. A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest cancer. Hydrocele is a painless swelling of the scrotum.

During DRE, a 46-year-old client cries out in pain as the nurse palpates his swollen, firm prostate. Which of the following problems should the nurse first suspect?

Prostatitis. The hallmarks of prostatitis are a tender, swollen, firm prostate. Tenderness is not normally present in cases of BPH or prostate cancer.

Mr. Jackson, 50 years old, has had discomfort between his scrotum and anus. He also has had some fevers and dysuria. Rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is the most likely diagnosis?

Prostatitis. This examination, associated with a history of dysuria, frequency, and incomplete voiding, should lead to a suspicion of acute prostatitis. Prostate cancer, colon cancer, and polyps should not ordinarily cause systemic symptoms such as fever.

The client with a acute appendicitis has been ordered a barium enema. What should the nurse do first?

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?

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.

A nurse prepares a male client for a physical assessment of the external genitalia. Which instruction is appropriate for the nurse to give the client before the examination?

Reassure him that it is not unusual to have an erection during the examination. The nurse should reassure the client that it is not unusual to have an erection during the examination; this will avoid unnecessary embarrassment in the client. The nurse should ask the client to empty the bladder before the examination so that he will be comfortable during the examination. The client should be informed that he may need to stand for most of the examination. The nurse should encourage the client to ask questions during the examination, and, at the same time, ease the client's anxiety by explaining in detail the significance of each portion of the examination.

When the nurse is examining a male client's genitalia, the client experiences an erection. What would be most appropriate for the nurse to do?

Reassure the client that this is not unusual. If a client experiences an erection during the exam, the nurse should reassure the client that this is not unusual and continue the exam in an unhurried and unflappable manner. The nurse needs to acknowledge the event, because the client is most likely feeling embarrassed. Stopping the exam and leaving the room may promote additional embarrassment or guilt in the client. Asking if continuing will embarrass him emphasizes what the client is already feeling and would most likely make it worse.

Upon examination of the rectum, the nurse notes a red, doughnut-like mass with radiating folds. The nurse suspects which of the following?

Rectal prolapse. Bulges of red mucous membrane or red doughnut like mass with radiation folds suggests a rectal prolapse. A small opening in the skin surrounding the anal opening suggests an anorectal fistula. A thrombosed swollen area would suggest an external hemorrhoid. Soft nodules inside the rectum may suggest polyps.

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 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.

The nurse is aware of the heightened risk of urinary tract infections in older males. In order to reduce this risk, the nurse should prioritize which of the following interventions?

Remove urinary catheters as soon as possible. Urinary tract infection (UTI), a type of HAI, accounts for more than 30% of infections reported by acute care hospitals in the United States. Virtually all hospital-associated UTIs are caused by instrumentation of the urinary tract, mainly from indwelling urinary catheters. Prevention of a catheter-acquired urinary tract infection (CAUTI) is a key component of an acute-care hospital's client safety and quality improvement program.

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?

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?

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."

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located?

Right upper quadrant The liver is the largest solid organ in the body. It is located below the diaphragm in the right upper quadrant of the abdomen.

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?

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.

A 29-year-old married computer programmer comes to the clinic complaining of "something strange" going on in his scrotum. Last month while he was doing his self-testicular examination he felt a lump in his left testis. He waited a month and felt the area again but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. Examination shows a muscular healthy young man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but has a large mass on the left. While placing a finger through the inguinal ring on the right, the examiner asks the client to bear down. Nothing is felt. The examiner attempts to place a finger through the left inguinal ring but cannot get above the mass. On rectal examination the client's prostate is unremarkable. What disorder of the testes is most likely?

Scrotal hernia. Scrotal hernias occur when the small intestine passes through a weak spot of the inguinal ring. The examiner cannot get a finger above the hernia into the ring. Hernias are often caused by increased abdominal pressure such as in weight lifting. Clients who have a hernia on one side often have another hernia on the opposite side.

During a class, a student asks the instructor, "What does the anal canal contain?" Which of the following would the instructor include in the response?

Somatic sensory nerves. The anal canal is lined with skin that contains no hair or sebaceous glands but does contain many somatic sensory nerves, making it susceptible to painful stimuli. The anorectal junction is also known as the dentate line.

During the physical assessment of a client's genitalia, the nurse notes an abnormal mass or swelling. The nurse performs transillumination by shining a light from the back of the scrotum through the mass. In which condition should the nurse see a red glow?

Spermatocele. When transilluminating the scrotal contents, a red glow is seen in swellings or masses that contain serous fluid such as spermatocele and hydrocele. Swellings or masses such as tumors, hernias, and varicocele that are solid or filled with blood do not light up with a red glow.

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?

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.

The nurse percusses the lowest interface in the left anterior axillary line, asks the client to take a deep breath, and percusses again. The nurse is assessing for which of the following?

Splenic percussion sign A change in the percussion note from tympany to dullness on inspiration in this location suggests splenic enlargement. The given procedure is the correct technique for assessing for a positive splenic percussion sign, not kidney tenderness, liver palpation, or diaphragmatic displacement.

Which of the following would a nurse suspect if dullness is percussed at the last interspace at the anterior axillary line on deep inspiration?

Splenomegaly Normally, tympany or resonance is heard at the last left interspace. Dullness suggest 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.

What would a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?

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 nurse performs light palpation of the abdomen and feels a prominent, non-tender, pulsating mass above the umbilicus that measures approximately six (6) centimeters. What is an appropriate action by the nurse?

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.

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?

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.

During the assessment of a client, the nurse recognizes that which of the client's lifestyle practice may predispose to the development of an inguinal hernia?

Strenuous activity. Strenuous activity and heavy lifting may predispose a client to the development of an inguinal hernia. Exposure to radiation and certain chemicals increases the risk of developing cancer. Erectile dysfunction occurs frequently in adult males and may be attributed to various factors, some of which include the use of alcohol, diabetes, or depression. Fear can cause stress and inhibition and decrease sexual satisfaction.

When inspecting the abdomen, which of the following client positions facilitates correct examination technique?

Supine with arms at sides or folded across chest. A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenburg, or semi-Fowler's position.

On inspection of a client's penis, the nurse observes a small, silvery-white papule. Which of the following conditions should the nurse suspect in this client?

Syphilitic chancre. Syphilitic chancre initially is a small, silvery-white papule that develops a red, oval ulceration. Herpes progenitalis is characterized by clusters of pimple-like, clear vesicles that erupt and become ulcers. Cancer of the glans penis appears as a hardened nodule or ulcer on the glans. Hypospadias is a condition in which the urethral meatus is located underneath the glans (ventral side).

An older adult client comes to the ED bleeding from the rectum. The client has a history of atrial fibrillation and has had two small strokes. The client is currently taking blood pressure medication and anticoagulation therapy at home. Why might this client need to be hospitalized?

The client is on anticoagulation medication. The client with rectal bleeding needs rapid assessment. Bleeding associated with anorectal problems can resolve spontaneously or with local pressure. The client undergoing anticoagulation therapy, however, may need hospitalization. The client's history of stroke or being an older adult would not be the deciding factor in hospitalization.

An uncircumcised male client has just come to the recovery room following a 4-hour back surgery. Before surgery a urinary catheter was placed. During the postoperative assessment, the recovery nurse discovers that the client has developed paraphimosis. What might have happened to the client to cause this?

The foreskin was not pulled back over the head of the penis after catheter placement. Paraphimosis occurs when the retracted prepuce cannot be placed back over the glans. Paraphimosis may be severe enough to restrict circulation to the glans. An uncircumcised male should always have the foreskin pulled toward the urethral opening. The other options are distracters to the question.

Which of the following statements provides the most accurate guide to the assessment of the gallbladder?

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Because the gallbladder is deep to the liver, it is normally not amenable to direct examination by auscultation, palpation, or percussion. This does not mean, however, that cholecystitis and cholelithiasis cannot be assessed for a thorough history. The gallbladder and the spleen are not proximate.

After teaching a group of students about the anal canal, the instructor determines that the teaching was successful when the students state which of the following?

The internal sphincter is under involuntary control. The anal canal is the final segment of the digestive system; it begins at the anal sphincter and ends at the anorectal junction (also known as the pectinate line, mucocutaneous junction, or dentate line). It contains two sphincters. The external sphincter is composed of skeletal muscle and is under voluntary control. The internal sphincter contains smooth muscle and is under involuntary control.

villi

Tiny finger-shaped structures that cover the inner surface of the small intestine and provide a large surface area through which digested food is absorbed. Tiny finger-shaped structures that cover the inner surface of the small intestine and provide a large surface area through which digested food is absorbed.

A nurse is assessing the genitalia of a male client. The nurse finds that the client has a piercing in his penis. Why is it important to investigate details of the piercing?

To assess for health risks relating to how it was performed. The nurse needs to know where and how the piercing was done, because health risks such as hepatitis, tetanus, and tuberculosis, among other diseases, are possible when procedures are performed in an unsterile environment. U.S. laws concerning piercing vary in each state, so the nurse should not automatically call the authorities. The nurse can teach optimal care of the site, but this is less important than ascertaining greater health risks first. The nurse should never unprofessionally try to get information to facilitate personal preferences.

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?

Tympany Generalized tympany predominates over the abdomen because of air in the stomach and intestines. Dullness is heard over the liver and spleen. Accentuated tympany or hyperresonance is heard over a gaseous, distended abdomen.

A 27-year-old policewoman comes to the clinic with severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate, but she has no burning on the outside. She has had no frequency or urgency with urination, but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative, and her urine analysis shows red blood cells. What type of urinary tract pain is she most likely to have?

Ureteral pain (from a kidney stone) The pain from a kidney stone causes dramatic, severe, colicky pain at the costovertebral angle that radiates across the flank and down into the groin.

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?

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.

The nurse is assessing a patient's gait. Which factors should the nurse observe as the patient ambulates in the room? (Select all that apply.)

base support, stride, arm swing, posture. Rationale:When assessing a patient's gait, the nurse should observe for base of support, weight-bearing stability, foot position, stride, arm swing, and posture. The nurse would not focus on the patient's breathing when ambulating.

CAUTI

catheter acquired urinary tract infection

During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document this finding?

characteristic symptoms

The inguinal canal in a male client is located

just above and parallel to the inguinal ligament. The internal inguinal ring is the internal opening of the inguinal canal. It is located 1 to 2 cm above the midpoint of the inguinal ligament and cannot be palpated.

A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness?

light palpation Light palpation aids in the detection of abdominal tenderness by allowing palpation without aggravating pain. Deep palpation requires that the nurse press down 5 to 8 cm (2 to 3 inches) which may cause the client further discomfort or pain. Deep palpation is warranted to delineate edges of abdominal organ masses. Percussion helps to assess the amount of gas throughout the abdominal viscera and masses that are solid or fluid filled. Auscultation allows the nurse to listen for bowel sounds.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible

masses. A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue.

The prostate gland consists of two lobes separated by the

median sulcus. The prostate gland consists of two lobes separated by a shallow groove called the median sulcus.

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's

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.

sis

state of, condition of

-stasis

stopping, controlling. sitting still.

The testes in the male scrotum are

suspended by the spermatic cord.

Lymphadenopathy (LAD)

swollen lymph nodes

Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is

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 nurse is assessing a client with a history of alcohol abuse. The client reports right upper quadrant pain. Which type of pain is the client experiencing?

visceral Visceral pain in the right upper quadrant often suggests liver distension and may be related to alcohol hepatitis. Parietal pain originates from inflammation in the parietal peritoneum also known as peritonitis. Referred pain is felt in the more distant sites, which are innervated at approximately the same spinal levels as the body structure that is inflamed. Right upper quadrant pain is not related to or caused by any problems of the musculoskeletal system.