abdominal assessment prep u-questions
A nurse observes 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 regards to this finding?
-"How many times have you been pregnant?"
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
Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause?
-An enlarged liver felt during palpation
A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend?
-Avoid excessive alcohol intake
Older adults often have trouble with swallowing. What might cause this?
-Decreased saliva production
Which of the following people need to be vaccinated for hepatitis A and B?
-Food-service workers
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 nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation?
-identify abdominal organs
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?
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
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
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?
-crohns disease
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
A 23-year-old man has recently graduated from university and is preparing to embark on a backpacking trip around Southeast Asia. In preparation for his trip, the client has visited a clinic to obtain vaccinations. The client will be able to obtain vaccines protecting against which of the following?
-Hepatitis A and B
The nurse as elicited a positive Murphy sign. The knows this is indicates what?
-Inflammation of the gallbladder
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
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?
-It is a splenic rub.
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 assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C (99.3°F;). Which of the following interventions is appropriate for this client?
-Monitor pulse and blood pressure every 15 minutes until stable
To promote relaxation of the client's abdominal muscles, what would be most appropriate for the nurse to do?
-Place a pillow under both of the client's knees.
The nurse correctly identifies the gallbladder is located where?
-RUQ
The nurse plans to assess a client's liver border. Which area of the abdomen is the nurse going to assess?
-RUQ
Which nursing diagnosis is most appropriate for an elderly client with poor dentition?
-Risk for Imbalanced Nutrition: Less Than Body Requirements
Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus?
-Stop palpating and get medical assistance.
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.
A client reports severe pain in the left lower quadrant of three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history?
-The left lower quadrant is palpated last
The peritoneum is a serous membrane that contains which of the following?
-a parietal layer
A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following?
-absent
A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. What bowel sound would the nurse expect to assess in this client?
-absent
A 26-year-old sports store manager comes to the clinic with severe right-sided abdominal pain for 12 hours. He began having a stomach ache yesterday with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 38.8° and his heart rate is 170. His bowel sounds are decreased, and he has rebound and involuntary guarding at one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain?
-acute appendicitis
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?
-appendicitus
The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area?
-auscultation
While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound?
-borborygmus
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?
-bowels sounds normal
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
Why is the appearance of urine important to evaluate during an abdominal examination?
-dark urine may be from dehydration
A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process?
-internal adhesions from previous surgery
The nurse performs the technique shown when assessing a client. For what is this nurse assessing?
-kidney tenderness
The nurse is assessing an older adult client for severe malnutrition. Which of the following factors increases this client's risk for malnutrition?
-limited access to a grocery store
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
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 min
A patient's most recent laboratory results indicate increases in alanine aminotransferase (ALT) and aspartate aminotransferase (AST). What might the nurse suspect is wrong with this patient?
-liver disease
The nurse performs the assessment technique shown. What is the nurse assessing in this client?
-liver size
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
You are assessing a patient for acute cholecystitis. What sign would you assess for?
-murphy sign
Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure?
-overflow incontinence
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should
-palpate deeply while quickly releasing pressure.
A client reports the onset of pain in the left upper quadrant of the abdomen with the ingestion of alcohol. The nurse recognizes that alteration in function of which organ is most likely to be the cause of this pain?
-pancreas
A client complains of abdominal pain that is worsened with alcohol ingestion. The nurse should suspect which of the following as the underlying cause?
-pancreatitis
The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible
-paralytic ileus.
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 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 rovings sign
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
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
To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's
-right lower quadrant
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's
-right upper quadrant
The nurse understands this abdominal organ is responsible for storing red blood cells and platelets.
-spleen
Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?
-spleen
What would a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?
-splenomegaly
A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of
-stomach ulcers
The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?
-tympany
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
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 min
