HA prepU ch 20 abdominal assessment
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 identifies the client has a positive Obturator sign. The nurse identifies this is due to what?
Appendicitis
While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible
Umbilical hernia
A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem?
Visible peristaltic waves
A nurse performs percussion beginning along the left mid-axillary 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
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?
Abdominal aortic aneurysm
A client's bladder is found to be distended. At which location should the nurse begin palpating?
At the symphysis pubis
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
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?
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?
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?
Family history; dietary habits
Which of the following people need to be vaccinated for hepatitis A and B?
Food-service workers
A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause?
Helicobacter pylori
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
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
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
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 5 minutes
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 at least five minutes before documenting an absence of bowel sounds.
To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do?
Place a pillow under both of 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 Rovsing's sign
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
To palpate 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
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 3 days' duration. How should the nurse conduct palpation of the abdomen due to this history?
The left lower quadrant is palpated last
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
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
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
A client reports having chronic discomfort in the upper abdomen. The nurse can be certain that this client is experiencing dyspepsia when which symptoms are present?
felling fullness after eating, satiation early in meal, epigastric burning
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
While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating what complication?
inflection
Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure?
overflow incontinence
A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor?
overuse of laxatives
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should
palpate deeply while quickly releasing pressure
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
The nurse understands that the liver does what?
produces clotting factors
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
When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant?
right kidney, ascending colon, liver
When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach.
true