HA, Abdominal Assessment

During the assessment of a client's urinary system, the nurse learns that the client has painful urination. Which term will the nurse use when documenting this finding in the client's medical record? 1. Dysuria. 2. Hematuria. 3. Oliguria. 4. Polyuria.

1

The nurse is caring for a client admitted with an infection of the ureters. The nurse realizes this infection could include which structure of the kidney? 1. Capsule. 2. Cortex. 3. Medulla. 4. Pelvis.

4

The nurse is interviewing the parents of a toddler who state they are concerned about the child's bedwetting. Which response by the nurse is the most appropriate? 1. ""Be sure to limit the child's fluid intake during the evening." 2. "Don't worry; all children wet the bed." 3. "We'll obtain a specimen to check for a urinary tract infection." 4. "This problem will be gone at the age of 4."

1

The nurse is palpating the left flank area and feels a sharp edge with definite delineated margins. Based on this data, which is the nurse palpating? 1. An enlarged spleen. 2. An enlarged kidney. 3. The colon. 4. A distended bladder.

1

The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse notes that the liver span is approximately 11 centimeters. How will the nurse document this finding in the medical record? 1. Hepatomegaly. 2. A normal finding. 3. Related to recent diagnosis of chronic bronchitis. 4. Presence of ascites.

1

The nurse is planning to palpate a client's bladder. Over which area of the abdomen should the nurse palpate? 1. Hypogastric region 2. Left lower quadrant 3. Epigastric region 4. Right lower quadrant

1

The pediatric nurse is preparing an educational presentation for parents of school-aged children regarding hepatitis. Based on the pediatric risk, which type of hepatitis virus will the nurse focus on during the educational session? 1. Hepatitis A virus. 2. Hepatitis B virus. 3. Hepatitis C virus. 4. Hepatitis D virus.

1

The nurse documents an abdomen that is bulging and stretched in appearance as: 1. rounded 2. herniated 3. scaphoid 4. protuberant

4

The nurse is performing an abdominal assessment on an infant. The nurse notes that the umbilicus is bulging and has been displaced slightly to the left of midline. Based on this data, which diagnosis does the nurse anticipate? 1. Infection. 2. Umbilical hernia. 3. Ventral hernia. 4. Hiatal hernia.

2

The nurse is assessing the client's abdomen and notes dullness when percussing over the left lower quadrant. Which question is most appropriate for the nurse to ask the client at this time? 1. "How much alcohol do you drink?" 2. "Do you have pain after eating?" 3. "When was your last bowel movement?" 4. "Have you ever had splenomegaly?"

3

The nurse is able to percuss a dull tone over a client's bladder after the client has voided 300 ml of urine. Which conclusion by the nurse is the most appropriate? 1. This is a normal finding. 2. Possible urinary tract infection. 3. This is a sign of prostate enlargement. 4. Probable urinary retention.

4

The nurse is teaching an adult client who is participating in rehabilitation for bladder retraining. Which amounts of urine would cause the bladder to distend above the symphisis pubis? 1. 100 ml. 2. 200 ml. 3. 500 ml. 4. 700 ml.

4

The nurse is caring for an infant with newly diagnosed renal disease. Diagnostic tests for which system is the priority for this infant? 1. Ears. 2. Heart. 3. Lungs. 4. Joints.

1

The nurse recognizes normal findings when assessing the abdomen of a healthy infant include: Select all that apply. 1. visible peristaltic waves 2. abdominal respirations 3. increased tympany with percussion 4. a palpable liver edge 5 centimeters below the costal margin 5. "potbelly" appearance

1, 2, 3, 5

The nurse utilizes deep palpation during the abdominal assessment to determine: Select all that apply. 1. hepatomegaly 2. splenomegaly 3. superficial tenderness 4. masses 5. bowel motility

1, 2, 4

The nurse is mapping the client's abdomen into four quadrants. Which landmarks would the nurse use to perform this assessment? Standard Text: Select all that apply. 1. Umbilicus. 2. Midclavicular lines. 3. Xiphoid process. 4. Lower border of the right ribs. 5. Iliac crests.

1, 3

The nurse is preparing an educational session on kidney health for a church group. Which would the nurse include as the leading causes of end-stage renal disease? Standard Text: Select all that apply. 1. Diabetes mellitus. 2. Alcoholism. 3. Hypertension. 4. Cardiovascular disease. 5. Obesity.

1, 3

The nurse is assessing a client admitted for oliguria of unknown origin. During the admission, the client asks the nurse what affects urinary output. Which responses are appropriate by the nurse? Standard Text: Select all that apply. 1. Bladder size. 2. Bowel patterns. 3. Medications. 4. Client temperature. 5. Fluid intake.

1, 3, 4, 5

The nurse is completing an abdominal assessment and is percussing over the left side of the upper portion of the client's abdomen over the area of the stomach. The client states, "I haven't had my breakfast, yet." Based on this statement, which does the nurse anticipate? 1. Dullness. 2. Flatness.. 3. Tympany. 4. Hyperesonance.

3

The nurse is interviewing a client who states the presence of urinary incontinence with coughing and sneezing. Which term will the nurse use when documenting this finding in the medical record? 1. Functional. 2. Reflex. 3. Stress. 4. Urge.

3

The nurse is interviewing an older adult client in the clinic who reports incontinence. Numerous attempts in the recent past have been unsuccessful in helping to control the problem. Which is the priority diagnosis for this client? 1. Skin integrity impairment. 2. Self-care deficit. 3. Self-esteem, situational-low. 4. Infection.

3

The nurse is percussing the abdomen of an adult and notes a liver span of 8 centimeters above the right costal margin. The nurse should: document the presence of hepatomegaly ask additional history questions regarding the client's alcohol intake consider this a normal finding and proceed with the examination auscultate over the area

3

A client has a spinal cord injury with paralysis at C5 level. When completing discharge teaching, which client statement would require further teaching? 1. "I need to perform self-catheterization three times daily." 2. "I know I cannot look to see if my bladder is full." 3. "I need to avoid bladder distention." 4. "I'll drink adequate amounts of liquids."

1

A client is admitted with possible renal calculi. The client asks, "Are there are any tests that can be performed to show the doctor if there are any kidney stones?" Which response by the nurse is the most appropriate? 1. "The intravenous pyelogram will allow the healthcare provider to visualize kidney stones." 2. "A 24-hour urine specimen will allow the healthcare provider to visualize kidney stones." 3. "A routine urinalysis will allow the healthcare provider to visualize kidney stones." 4. "A kidney biopsy will allow the healthcare provider to visualize kidney stones."

1

A postpartum client with a difficult vaginal delivery 36 hours ago tells the nurse that she has not felt the need to void much since delivery. Which response by the nurse is the most appropriate? 1. "The inside of your bladder is most likely swollen, which makes you feel like you don't have to urinate." 2. "You must be overdoing it with your activity level so soon after delivery." 3. "I will need to catheterize you." 4. "Your uterus must not be enlarged any longer."

1

During auscultation of the abdomen, the nurse notes the presence of borborygmi. What does this finding indicate to the nurse? Hyperactive bowel sounds A bruit A possible bowel obstruction Hypoactive bowel sounds

1

During the assessment of a client with multiple injuries, the nurse notices a large hematoma located at the left costovertebral angle. The nurse should suspect injury to which organ? 1. Kidney. 2. Ribs. 3. Intestines. 4. Bladder.

1

Since returning from surgery the client has not voided for 8 hours; therefore, the nurse determines it is necessary to assess the client for bladder distention. Which client position is appropriate for this assessment? 1. Supine with only a small pillow under their head. 2. Prone position. 3. Sitting in bed at a 45-degree angle. 4. Lying in a left lateral position.

1

The client states, "No one will let me eat or drink anything until after my test and it's been 9 hours since I last ate anything!" While auscultating the client's abdomen the nurse hears frequent bowel sounds. How will the nurse document this finding in the medical record? 1. Borborygmi present. 2. Hypoactive bowel sounds present. 3. Bruit present. 4. Friction rub present.

1

The nurse is assessing a client after a motor vehicle accident and notes the presence of ecchymosis in the left flank area. Which interpretation of this data is the most accurate? 1. Positive Grey Turner sign. 2. Costovertebral angle tenderness. 3. Possible clotting dysfunction. 4. A precursor to hematuria.

1

The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back. The client states, "This has been happening more often after I eat rich, high-fat foods." Which disorder does the nurse suspect based on these findings? 1. Cholecystitis. 2. Duodenal ulcer. 3. Gastritis. 4. Pancreatitis.

1

The nurse is performing an abdominal assessment on a client. While the nurse is palpating the lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client complains of a sharp pain located in the right upper quadrant. How will the nurse document this finding in the medical record? 1. Positive Blumberg sign. 2. Presence of pain at McBurney point. 3. Positive Murphy sign. 4. Positive Psoas sign.

3

The nurse is palpating the right upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Standard Text: Select all that apply. 1. Liver. 2. Gallbladder. 3. Appendix. 4. Spleen. 5. Stomach.

1, 2

The nurse is interviewing an older adult Hispanic client who complains of recent weight loss, anorexia, and epigastric pain. The client reports recent use of "mints" for stomach upset. Based on this assessment data, which interventions are appropriate for this client? Standard Text: Select all that apply. 1. Schedule the client for an endoscopy as ordered. 2. Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider. 3. Educate the client regarding Helicobacter pylori infections. 4. Discuss the importance of using over-the-counter aspirin for mild pain relief. 5. Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer.

1, 2, 3

A client presents with a medical diagnosis of uremia. Which clinical manifestations does the nurse anticipate upon assessment? Standard Text: Select all that apply. 1. Itching. 2. Weight loss. 3. Altered mental status. 4. Fluid retention. 5. Insomnia.

1, 2, 3, 4

The nurse is interviewing a client regarding urinary health. Which response would the nurse include during the collection of subjective data? Standard Text: Select all that apply. Copyright 2016 by Pearson Education, Inc. 1. "Do you have difficulty starting your stream of urine?" 2. "After you urinate, does your bladder feel full or empty?" 3. "Do you ever have an accident or wet yourself when you sneeze?" 4. "Do you have to hurry to the bathroom when you have to urinate?" 5. "Your recent urinalysis reveals protein in the urine."

1, 2, 3, 4

The nurse is performing an abdominal assessment on a client. During the focused interview, the client tells the nurse about experiencing some abdominal pain recently. As the nurse assesses the client, which behaviors indicate that the client may be experiencing pain or anxiety during the examination? Standard Text: Select all that apply. 1. The client's respiratory rate is 26 per minute. 2. The client moves away from the nurse's hands. 3. The client grimaces. 4. The client pulls his knees toward his stomach. 5. The client coughs loudly.

1, 2, 3, 4

The nurse is preparing a client for assessment of the urinary system. Which technique will the nurse include in this physical assessment? Standard Text: Select all that apply. 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Client interview.

1, 2, 3, 4

The nurse understands the presence of dullness on percussion of the abdomen may be the result of: Select all that apply. 1. an enlarged uterus 2. bladder distention 3. stool in the colon 4. ascites 5. gastric bubble

1, 2, 3, 4

The nurse is preparing an educational presentation regarding the Healthy People 2020 objectives. Which topics are appropriate and related to the objectives? Standard Text: Select all that apply. 1. Educate pregnant women regarding the importance of small, more frequent dry meals throughout the day to reduce nausea and vomiting. 2. Educate Asian men about the importance of avoiding alcohol because this is a population that is prone to alcohol abuse. 3. Educate people who are anticipating traveling to India, Asia, Africa, or Central America about ways to reduce their risk of becoming infected with hepatitis E virus. 4. Educate immunocompromised populations and those caring for them about the importance of safe food handling. 5. Educate people about the relationship between regular, thorough oral hygiene practices and good nutrition.

1, 3, 4, 5

An adolescent client is seen for abdominal pain in the local clinic. The client states, "The pain is sort of all over my belly. I can't really find one place that hurts more than another area." Based on the nurse's understanding about disorders of abdomen and associated symptomatology, which nursing diagnoses are appropriate for this client? Standard Text: Select all that apply. 1. Acute pain. 2. Hypothermia. 3. Diarrhea. 4. Altered urinary elimination. 5. Altered nutrition, less than body requirements.

1, 3, 5

A client asks the nurse, "What's the purpose of the liver?" Which statements will the nurse include in the response to this client's question? Standard Text: Select all that apply. 1. "It helps you digest fats." 2. "It is an endocrine and exocrine gland." 3. "It filters waste from the blood and makes urine." 4. "It makes some blood-clotting substances." 5. "It can help you store certain vitamins."

1, 4, 5

The nurse is preparing to examine a client who is complaining of right lower quadrant abdominal pain. Which actions by the nurse are appropriate in this situation? Standard Text: Select all that apply. 1. "It is a little cool in our examination room; may I turn up the thermostat?" 2. "I've been told you are experiencing some pain in the lower right area of your abdomen. I will examine that area first." 3. "I am going to stand on your left side so I can feel your liver better." 4. "I'm going to place this drape over you so you don't feel too exposed during this examination." 5. "I am going to place this pillow behind your head and this pillow under your knees."

1, 4, 5

A client asks the nurse, "What's the purpose of a gall bladder anyway? My mom lived for many years without her gallbladder." Which information would be beneficial for the nurse to share with this client? 1. "You are right. We still don't know the function of the gallbladder." 2. "It stores bile until it is needed for digestion of fats." 3. "It destroys old red blood cells." 4. "It helps you digest carbohydrates by producing enzymes."

2

A client reports having an abdominal hernia and asks the nurse to briefly describe what a hernia is. The nurse should: Hint: Abnormal Findings; Abdominal Hernias refer the client back to the healthcare provider for an explanation explain that a hernia is a protrusion of an organ or structure through a weak spot in the abdominal wall explain that hernias are common in adulthood and caused by poor muscle tone tell the client that most men develop abdominal hernias

2

A client's blood pressure suddenly falls from 120/80 mmHg to 90/60 mmHg. Which major role of the kidney is causing this clinical manifestation? 1. Increasing hydrostatic pressure. 2. Release of renin. 3. Increasing glomerular filtration rate. 4. Dilation of renal vessels.

2

A toddler has been diagnosed with gastroenteritis. The nurse's priority when assessing this child should be: breath sounds hydration status heart sounds musculoskeletal assessment

2

An older adult female comes into the clinic to be seen for urinary incontinence. Which conclusion by the nurse is the most appropriate? 1. Is common with aging. 2. Often occurs as a secondary problem. 3. Indicates decreased renal blood flow. 4. Is related to medications.

2

An older adult tells the nurse, "I try not to drink much water because it makes me have to go to the bathroom more often." The most appropriate response made by the nurse is: 1. "Do you experience heartburn?" 2. "Decreased fluid intake can contribute to the development of constipation." 3. "This may be the reason for your diarrhea." 4. "Decreased water intake may make your hemorrhoids worse."

2

The nurse is admitting a client with constant, severe flank pain, spasms, nausea and vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the low back to the lower quadrants of the abdomen. Which nursing action is the priority for this client? 1. Administer pain medication. 2. Notify the healthcare provider immediately. 3. Obtain a urine specimen for culture. 4. Complete the assessment.

2

The nurse is caring for a client diagnosed with the hepatitis A virus. The client requests information about how the virus is transmitted. Which statement by the nurse is appropriate? 1. "This virus is transmitted by sexual contact with someone who already has been infected with this virus." 2. "Most likely, you ate something that was contaminated with the virus." 3. "It is spread by blood transfusions." 4. "Have you ever injected an illegal drug?"

2

The nurse is obtaining a medication history on a newly admitted client with renal dysfunction. Which medication classification would the nurse note as significant for this client? 1. Antihypertensives. 2. Analgesics. 3. Antihyperlipidemics. 4. Diuretics.

2

The nurse is percussing over the client's symphysis pubis area and notes a dull tone. Which conclusion by the nurse is the most appropriate based on the data? 1. He or she is assessing the right kidney. 2. A full bladder. 3. A bladder tumor. 4. Air trapped in the intestines.

2

The nurse is preparing an educational session on kidney health for a church group. Which group would the nurse note to have the highest incidence of end-stage renal disease? 1. Mexicans. 2. Asians. 3. African Americans. 4. American Indians.

3

The nurse is performing a focused interview with an older adult client. Which statements by the client are expected? Standard Text: Select all that apply. 1. "I have been having loose stools every day for the last 3 years." 2. "I know I just don't drink as much water as I should." 3. "My belly seems softer and flabbier as I get older." 4. "My mouth is always dry." 5. "My heartburn gets worse the older I get."

2, 3, 4

The nurse is completing discharge instructions for a client admitted with esophagitis. Which client statements indicate the need for further education? Standard Text: Select all that apply. 1. "I'm going to talk to my doctor about a nicotine patch." 2. "I can do all of this stuff you're talking about as long as I don't have to give up my beer." 3. "I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle." 4. "The root of this problem is that I just sleep too much." 5. "I told my wife to stop making serving me all of those vegetables."

2, 4, 5

The nurse is assessing a client in the emergency department (ED) who complains of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. Based on the client's assessment data, which conditions does the nurse suspect? Standard Text: Select all that apply. 1. Constipation. 2. Appendicitis. 3. Cholecystitis. 4. Small bowel obstruction. 5. Peritonitis.

2, 5

The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. As the nurse inspected the client's abdomen and notes ascites. Based on this data, which interventions will the nurse perform next? Standard Text: Select all that apply. 1. Obtain stool specimen for occult blood. 2. Measure the client's abdominal girth. 3. Obtain stool specimen for culture and sensitivity. 4. Bilateral leg measurements. 5. Percuss the abdomen at midline.

2, 5

An older adult comes into the clinic with difficulty swallowing. How should the nurse document this client's concern? Esophagitis Odynophagia Dysphagia Aphasia

3

During the assessment of a client's renal system, the nurse is unable to palpate the kidneys. Which conclusion by the nurse is the most appropriate? 1. An indication of an inflammatory condition of the kidneys. 2. A sign of acute or chronic renal disease. 3. Normal. 4. A sign of polycystic kidney disease.

3

The nurse has inspected a client's abdomen in the supine position. What is the next step in the abdominal assessment? 1. Percussion 2. Palpation 3. Auscultation 4. Inspection of the abdomen in the sitting position

3

The nurse is preparing to catheterize a client who has just voided. Which is the purpose of this catheterization? 1. To obtain a baseline urine output. 2. To support the diagnosis of kidney stones. 3. To evaluate the ability of the client to empty the bladder. 4. To evaluate renal function.

3

When palpating the abdomen of a client, the nurse notes the presence of tenderness in the left upper quadrant (LUQ). The nurse suspects the organ most likely to be involved is the: appendix liver spleen gallbladder

3

When performing an abdominal assessment, the nurse knows that: 1. The gallbladder is normally palpable in adults. 2. The pancreas is palpable in the midepigastric area. 3. Tender areas should be assessed last. 4. It is normal to have pain with deep palpation of the liver.

3

Which client should the nurse refer to the healthcare provider for evaluation of weight loss? Young adult with 10-pound weight loss over 6 months who has given up drinking sugary sodas Older adult with 5-pound weight loss over past 2 months after the death of the client's spouse Middle-aged adult with 15-pound weight loss in 6 weeks, no change in diet or exercise routine Adult with 70-pound weight loss over 8 months after elimination of processed foods from diet and workouts with a personal trainer

3

An adolescent visits the school nurse to ask why she is getting frequent urinary tract infections. Which questions should the nurse ask the client during this visit? Standard Text: Select all that apply. 1. "Have you been eating foods that have high acidity?" 2. "Do you drink a lot of milk?" 3. "Do you take bubble baths frequently?" 4. "What direction do you wipe after a bowel movement?" 5. "Do you have a family history of urinary tract infections?"

3, 4

A client experienced blood loss from surgery. What is the impact of this blood loss on the kidney's functioning? 1. Altered filtering ability of the kidneys. 2. No impact on kidney function. 3. Absorption of calcium and phosphate decreased. 4. Stimulation of the kidneys to produce erythropoietin.

4

An older adult tells the nurse, "I feel full after eating small amounts of food, and I just can't eat as much as I used to." The nurse knows that this is a normal finding most likely related to: decreased absorption of nutrients atrophy of muscle fibers and mucosal surfaces decreased gastric acid production delayed gastric emptying times

4

The client was recently admitted to the hospital with left lower quadrant pain. The client states, "It feels like my belly is cramping." During the focused interview, the client admitted to experiencing a significant amount of occupational stress. Guarding is noted during the abdominal examination. The nurse reviews the medical record (see chart below) and concludes that the client has developed a diverticulitis. Which client statement supports this conclusion by the nurse? White blood cell count 25,000/mm 3 Red blood cell count 4.2 x 10 12 /L Temperature 101.2 degrees Fahrenheit Blood pressure 152/84 1. "I get home so late at night, but I've got to stop lying down right after dinner." 2. "I drink a whole pot of coffee every day." 3. "I drink 9-12 beers after I get home from work, every day." 4. "We have been growing green beans in our garden and I think I ate too many the other day."

4

The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the stethoscope. The nurse hears a soft, continuous humming sound. Based on this data, the nurse suspects dysfunction with which organ? 1. Stomach. 2. Spleen. 3. Pancreas. 4. Liver.

4

The nurse is collecting a urine specimen from a client and notes the urine is foamy and amber in color. Based on this data, which diagnosis would the nurse suspect? 1. Kidney stones. 2. Urinary tract infection. 3. Prostate disease. 4. Liver disease.

4

The nurse is documenting the findings of an abdominal assessment on a client and documents the following information, "pain noted during palpation at McBurney point." How did the nurse elicit this response during the assessment? 1. The nurse lightly palpated the around the client's umbilicus. 2. The nurse pressed into the client's abdomen and then pulled his hand back quickly. 3. The nurse palpated over the client's spleen. 4. The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.

4

The nurse is measuring the urinary output for a client and notes 450 ml of urine. Which conclusion by the nurse is the most appropriate? 1. Decreased from normal. 2. Concentrated from what is normal. 3. Increased from normal. 4. Normal amount.

4

The nurse learns a client has been taking more than three times the recommended amount of an over-the-counter pain (OTC) reliever on a daily basis for several months. On the basis of this finding, which of the following is the nurse most concerned about? 1. Potential for alterations in pancreatic enzyme production 2. Potential for gallbladder alterations 3. Potential for variation in insulin metabolism 4. Potential for liver function alterations

4

Which is a normal finding in the abdominal assessment of an adult? 1. Rebound tenderness in the right lower quadrant 2. A palpable spleen between the ninth and eleventh ribs in the left midaxillary line 3. Shifting dullness 4. A tympanic percussion note in the umbilical region

4

The nurse is palpating the left upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Standard Text: Select all that apply. 1. Liver. 2. Gallbladder. 3. Appendix. 4. Spleen. 5. Stomach

4, 5

The nurse is performing an abdominal assessment on the client. Rank the assessment steps in the order in which they should occur. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. 1. Percuss the abdomen. 2. Visualize the quadrants of the abdomen. 3. Palpate the abdomen. Copyright 2016 by Pearson Education, Inc. 4. Auscultate the abdomen. 5. Encourage the client to void.

5, 2, 4, 1, 3