CH. 7

when assessing the abdomen the nurse would expect to auscultate which sound ? A.high-pitched gurgling B. low-pitched rumbling C. bruits D. friction rubs

A. high pitched gurgling

the nurse palpates an accumulation of fluid in abdomen and documents this as ascites. the nurse should also assess the client for which health problems as possible etiological factors? Select all that apply A. chronic obstructive disease B. cirrhosis C. congestive heart failure D. renal failure E. Appendicitis

BCD

the client is vomiting fecal-like material the nurse would expect to prepare the client for diagnostic testing to evaluate the client for which health problem? A. appendicitis B. diarrhea C. intestinal obstruction D. a disorder of throat

C. intestinal obstruction

When percussing the liver the nurse would expect to document which of the following findings?

dullness

when auscultating abdomen of adult client, the nurse is unable to hear bowel sounds. for how many minutes should the nurse listen to each quadrant of abdomen?

5 minutes

During a gastrointestinal assessment the client tells the nurse about experiencing chronic flatulence. which question should the nurse ask the client next? A. are you eating large amounts of broccoli and cauliflower? B. are you consuming bread products? C.is fish a staple in your diet? D. do you consume two quarts of water per day?

A. are you eating large amounts of broccoli and cauliflower?

The nurse finds ascites during assessment of the abdomen. The nurse would conclude that this is most likely associated with which of the following health problems? A. overhydration B. cirrhosis C. a mass D. trauma

B. cirrhosis

when palpating abdomen of adult client, the nurse that client winces in pain and assess the involuntary contraction of abdominal muscles. the nurse would document which of the following findings? A. referred pain B. guarding C. dullness D. gastric bubble

B. guarding

During assessment of abdomen, the nurse would perform which maneuver to palpate the spleen? A. lift client with right hand under rib cage and palpate the right upper quadrant with the left hand B. lift client with left hand under rib cage and palpate the left upper quadrant with right hand C. palpate for pulsations by placing a hand below xiphoid process D. palpate for rebound tenderness by pressing into abdomen with steady pressure while asking if client is experiencing pain

B. lift client with left hand under rib cage and palpate left upper quadrant with right hand

the adult client presents to the ambulatory care clinic with reports of not being able to chew and swallow easily. the nurse should evaluate the client for which possible contributing factor? A. bloating B. missing teeth or ill-fitting dentures C. GI bleeding D. pain

B. missing teeth or ill-fitting dentures

while performing a head to toe assessment of a client the nurse hears dullness over the left upper quadrant during percussion. what would be the next assessment the nurse should perform? A. inspection of area B. palpation of area C.Auscultation of entire abdomen D. inspection of respiratory excursion

B. palpation of area

the nurse is assessing a child and notes protruding umbilicus. how would then nurse document the finding? A. rounded abdomen B. ascites C. hernia D. a central striae

C. hernia

During inspection of the abdomen, the nurse notes silvery, shiny stretch marks. The nurse would document this finding as which of the following? A. shadows B. scars C. ascites D. striae

D. striae

When obtaining information about appetite from a client who reports not feeling hungry in the last few weeks, the nurse should ask the client which questions? Select all that apply. Has your weight changed? Can you complete a dietary recall? Have you had any changes in your elimination patterns? When did you notice your appetite change? Are you experiencing any additional symptoms associated with the weight change?

Has your weight changed? Can you complete a dietary recall When did you notice your appetite change are you experiencing any additional symptoms associated with weight change?

When assessing the abdomen, the nurse performs the following examination techniques. In which sequence should the nurse complete the assessment? Place the answers in the correct order. Auscultation Palpation Inspection Percussion

Inspection Auscultation Palpation Percussion

a pt with a history of cholecystitis is admitted to emergency department with reports of pain the nurse should assess this pain by palpating what area?

RUQ

To assess whether a client is having symptoms of abdominal problems, the nurse would ask him or her about which of the following? Select all that apply. Nausea Indigestion Vomiting Fever Dietary intake

nausea indigestion vomiting

During an abdominal assessment, an older adult female tells the nurse that she does not regularly include fruits or vegetables in her diet the nurse should develop a plan of care based upon which of the following nursing diagnosis? risk for constipation risk for diarrhea weight loss relation to poor nutrition risk for chronic pain related to poor nutrition

risk for constipation

The nurse inspects the client's abdomen and observes a concave shape. The nurse should document this using which of the following descriptions? flat rounded scaphoid protuberant

scaphoid

When assessing the client's abdomen, the nurse should position the client in which of the following positions? supine with pillow under head supine with pillow under knees and head sitting with head upright at 90 degree angle standing with feet slightly apart

supine with pillow under knees and head