23 Abdominal

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible

Internal bleeding Purple discoloration at the flanks (Grey-Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.

A client asks a nurse how she can decrease her risk of gallbladder cancer. Which statement by the nurse is appropriate?

"A history of gallstones is the most common risk factor." Explanation: Gallbladder cancer and gallstones (cholelithiasis) vary together in prevalence, making gallstones the most common risk factor. Women are affected at least twice as often as men with gallbladder cancer. Neither cigarette smoking nor alcohol intake is a risk factor.

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

A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenberg, or semi-Fowler's position.

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.

The abdominal contents are enclosed externally by the abdominal wall musculature—three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external

abdominal oblique. Explanation: The abdominal contents are enclosed externally by the abdominal wall musculature, which includes three layers of muscle extending from the back, around the flanks, to the front. The outermost layer is the external abdominal oblique.

Appendicitis

common in the young and usually presents with periumbilical pain that localizes to the right lower quadrant in an area known as McBurney's point, described as one third of the way between the anterior superior iliac spine and the umbilicus on the right. Rebound and guarding are common. Remote rebound or Rovsing's sign is also seen commonly when the course of appendicitis is advanced. Bowel movements are usually unaffected.

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant?

right upper The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal.

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

usually difficult to localize Explanation: 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

The nurse finds the client's abdomen to be distended. The nurse recognize distention may be caused by what? Select all that apply.

• Feces • Fluid • Fetus • Gas

A nurse observes the abdomen of a client and notices it to be distended below the umbilicus. The nurse recognizes this can be caused by which of these conditions? Select all that apply.

• Full bladder • Uterine enlargement • Ovarian tumor • Impacted colon Abdominal distention below the umbilicus can be observed with a full bladder, uterine enlargement (tumor or pregnancy), ovarian cysts or tumors, and an impacted colon. A pancreatic tumor would be apparent in the upper abdomen. A tumor on the kidney would be apparent in the flank area.

Hyperactive bowel sounds

"borborygmus" loud, prolonged gurgles characteristic of one's "stomach growling."

Left lower quadrant

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

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.

Nurse suspects abdominal aortic aneurysm when what is assessed?

Abdominal bruit Auscultation of abdomen would reveal bruit. May exhibit decreased femoral pulses, hypotension, cool extremities.

Nurse examines client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of abdomen?

Absent Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds.

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 infammation. Kidney tenderness is assessed posteriorly. The Blumberg assesses for rebound tenderness and the Murphy test is for inflammation of the gallbladder.

When palpating a client's liver, the nurse feels a firm edge. What would this indicate to the nurse?

Cirrhosis Abnormal liver findings include hepatomegaly and the firm edge of cirrhosis. A firm edge does not indicate liver failure or calcification. Splenomegaly is a distractor for this question.

The nurse assess for kidney tenderness at what location

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

Mr. Kruger, 84 years old, presents with a smooth lower abdominal mass in the midline, which is minimally tender. There is dullness to percussion up to 6 cm above the symphysis pubis. What does this most likely represent?

Enlarged bladder Explanation: It is possible that this represents a sigmoid colon mass, but this is less likely than an enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently cause partial urinary obstruction with bladder enlargement. If the mass resolves with catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A hernia would most likely not be dull to percussion. Midline abdominal wall tumours of this size would be unusual but could be discerned by having the client tense his abdominal muscles.

The nurse as elicited a positive Murphy sign. The knows this is indicates what?

Inflammation of the gallbladder Pain with breathing during while assessing Murphy sign is an indication of inflammation of the gallbladder Peritonitis is assessed with Blumberg sign. Kidney pain is assessed that CVA. Appendicitis is assessed with the iliopsoas muscle test.

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

Irregular, large liver Explanation: With his past history of colon cancer and recent weight loss and fatigue, a relapse of his colon cancer would be expected. Colon cancer usually metastasizes to the liver, creating hard, irregular nodules, which can sometimes be palpated on examination. A smooth large liver that is tender is often seen in hepatitis.

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

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

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

Large intestine Explanation: 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 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.

Your patient describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your patient?

Malabsorption syndrome Explanation: Malabsorption syndrome is characterized by stool that is typically bulky, soft, light yellow to gray, mushy, greasy or oily, sometimes frothy, and particularly foul-smelling, and it usually floats in the toilet.

A nurse cares for a client with a duodenal ulcer. The nurse knows that which characteristic of pain is generally associated with the client's condition?

May awaken the client at night Explanation: A client with duodenal ulcers would have severe pain that awakens him at night. The pain may not increase by the intake of food but may be relieved by it. The pain is unrelated to drinking water. The nature of the pain may vary and may not necessarily be throbbing.

You are assessing a patient 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.

During the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign?

Murphy's Murphy's sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. The obturator sign involves pain in the right lower quadrant as a result of the nurse flexing the client's hip and rotating the leg externally and internally while supporting the client's right knee and ankle. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.

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.

The nurse auscultates 20 clicks and gurgles over 1 minute when examining a patient's abdomen. How should the nurse document this finding?

Normal bowel sounds consist of clicks and gurgles that occur at an estimated frequency of 5 to 30 per minute. The nurse should document that the bowel sounds are normal. Twenty bowel sounds in a minute is not hyperactive, hypoactive, or inconsistent

A client has a history of multiple abdominal surgeries from a gunshot wound 3 years ago. The client is currently reporting severe abdominal pain. Auscultation reveals high-pitched, rushing sounds. These sounds could be a sign of what condition?

Partial bowel obstruction Bowel sounds increase and decrease and indicate GI motility. They may be hyperactive at a point above a partial bowel obstruction and decreased or nonexistent below the point of obstruction. Increased bowel sounds occur with diarrhea and early intestinal obstruction. Decreased bowel sounds occur with adynamic ileus and peritonitis. High-pitched, tinkling bowel sounds indicate intestinal fluid, air under tension in a dilated bowel, and inadequate bowel sounds. High-pitched, rushing sounds indicate partial intestinal obstruction.

A nurse assesses a client with a distended abdomen. Which action by the nurse demonstrates the correct way to assess the client for ascites?

Percuss the flanks from bed upward toward the umbilicus The nurse should test for shifting dullness by percussing the flanks from bed upward toward the umbilicus to assess for ascites. Auscultating for bowel sounds in all quadrants of abdomen may not give any indication about ascites. Inspecting the abdominal skin for vascularity and striae may indicate ascites but it does not confirm the presence of fluids. Palpating the abdomen lightly for areas of tenderness may not contribute to ascites assessment.

How should the nurse perform blunt percussion over the liver?

Place left hand on right lower rib cage, strike it with ulnar side of right fist

An elderly cognitively impaired client has been eating poorly. Because of this, what should the nurse assess for each shift?

Pressure ulcers Older cognitively and nutritionally impaired clients are at risk for pressure ulcers. Venous thromboembolism and risk for falls should be assessed but no because the client is nutritionally impaired. Aspiration in cognitively impaired clients is a risk.

A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?

Spleen Percussion of the spleen begins in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness. Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage and striking it with the ulnar side of the right fist. The costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a kidney problem such as infection (pyelonephritis), renal calculi, or hydronephrosis. The gall bladder is not percussed.

The nurse is preparing to palpate the client's spleen. What should the nurse instruct the client to do?

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

The nurse auscultates hyperactive bowel sounds in the ascending colon and absent bowel sounds in the descending colon. What is the nurse's best action?

Tell the client not to eat or drink anything. Bowel sounds increase and decrease and indicate GI motility. They may be hyperactive at a point above a partial bowel obstruction and decreased or nonexistent below the point of obstruction. The client may have a bowel obstruction and should not eat or drink anything, including medications by mouth. The nurse should then notify the healthcare provider of these findings. While the client is NPO, the client is usually on intravenous fluid. The nurse should not decrease the rate.

The nurse auscultates hyperactive bowel sounds in the ascending colon and absent bowel sounds in the descending colon. What is the nurse's best action?

Tell the client not to eat or drink anything. Explanation: Bowel sounds increase and decrease and indicate GI motility. They may be hyperactive at a point above a partial bowel obstruction and decreased or nonexistent below the point of obstruction. The client may have a bowel obstruction and should not eat or drink anything, including medications by mouth. The nurse should then notify the healthcare provider of these findings. While the client is NPO, the client is usually on intravenous fluid. The nurse should not decrease the rate.

The colon originates in this abdominal area: the

right lower quadrant. Explanation: 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.

The pancreas of an adult client is located

deep in the upper abdomen and is not normally palpable. The pancreas, located mostly behind the stomach deep in the upper abdomen, is normally not palpable. It is a long gland extending across the abdomen from the RUQ to the LUQ.

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.

The nurse assesses an adult male client's abdomen and observes diminished abdominal respiration. The nurse determines that the client should be further assessed for

peritoneal irritation. Explanation: Diminished abdominal respiration or change to thoracic breathing in male clients may reflect peritoneal irritation.