3611 Assessing the Abdomen

Over which abdominal regions should the nurse auscultate for friction rubs? 1 3 6 9

1 Rationale: 1 Friction rubs are auscultated over the epigastric region, or region 1 in the image. 3 Friction rubs are not auscultated over the hypogastric region, or region 3 in the image. 6 Friction rubs are not auscultated over the right lumbar region, or region 6 in the image. 9 Friction rubs are not auscultated over the left inguinal region, or region 9 in the image.

Ascites

Refers to abnormal accumulation fluid in the abdominal (peritoneal) cavity. The most common cause of is cirrhosis of the liver.

Which region of the body is assessing in the upper middle region (region 1) of the abdomen? (see next page for image and next slide for answer) Epigastric Umbilical Hypogastric Left hypochondriac

See next slide

When inspecting the skin of the abdomen, which surface characteristics would the nurse observe? Select all that apply. Striae Temperature Lesions and scars Tautness Venous return

Striae Lesions and scars Tautness Venous return Rationale: Striae When inspecting the skin of the abdomen, the nurse should look for striae. Temperature The temperature of the skin would be assessed on palpation, not inspection. Lesions and scars When inspecting the skin of the abdomen, the nurse should look for the presence of any lesions or scars. Tautness When inspecting the skin of the abdomen, the nurse should look for tautness. Venous return When inspecting the skin of the abdomen, the nurse should look for venous return.

McBurney sign

refers to rebound tenderness over McBurney's point in the lower right quadrant which suggests appendicitis, but it is not a test that is performed when then nurse suspects appendicitis.

Obturator muscle test

should be performed if the nurse suspects a ruptured appendix or pelvic mass, not if the nurse suspects appendicitis.

When inspecting the surface of the abdomen, which element regarding contour should be assessed? Skin texture Visibility of pubic bones Abdominal profile from naval to lateral side Abdominal profile from rib margin to pubis

Abdominal profile from rib margin to pubis Rationale: Skin texture Skin texture is not inspected when assessing contour. Visibility of pubic bones When assessing contour of the abdomen, the visibility of pubic bones is not considered. Abdominal profile from naval to lateral side When assessing contour of the abdomen, the profile from the naval to lateral side is not considered. Correct Abdominal profile from rib margin to pubis When inspecting the surface of the abdomen, the abdominal profile from the rib margin to the pubis should be inspected, viewed on the horizontal plane.

Which tool is the most widely accepted tool for assessing acute appendicitis? Ohmann score Alvarado score Murphy score The Pediatric Appendicitis Score

Alvarado score Rationale: Ohmann score The Ohmann score is a tool to assess abdominal pain but is not the most widely accepted. Correct Alvarado score The Alvarado score (also known as the MANTRELS [Migration of pain, Anorexia, Nausea/vomiting, Tenderness in the right lower quadrant, Rebound pain, Elevation of temperature, Leukocytosis, Shift to the left] score is the most widely used score) for assessing acute appendicitis. Murphy score The Murphy score is not used to assess abdominal pain. The Pediatric Appendicitis Score The pediatric appendicitis score is a tool to assess abdominal pain but is not the most widely accepted.

The image demonstrates palpation of which abdominal structure? Kidney Pancreas Liver Stomach

Answer on next slide

The nurse should percuss the abdomen to obtain which information? Select all that apply. Detect masses Detect ascites Assess bowel sounds Detect gastric distention Assess the size of the organs

Assess the size of the organs Detect ascites Detect gastric distention Detect masses Rationale: Detect masses The nurse should percuss the abdomen to detect the presence of air-filled or fluid-filled masses. Detect ascites The nurse should percuss the abdomen to detect the presence of fluid, or ascites. Assess bowel sounds The nurse would identify bowel sounds by auscultation, not percussion. Detect gastric distention The nurse should percuss the abdomen to detect the presence of air, or gastric distention. Assess the size of the organs The nurse should percuss the abdomen to assess the size and density of the organs.

Which technique to identify an abdominal organ or mass is illustrated in the image? (image of pressing down with the tips of the fingers and feeling with both palms, one on each side of the trunk. See an example image on next slide for ballottement Ballottement Obturator muscle test McBurney sign Iliopsoas muscle test

Ballottement Rationale: Ballottement Ballottement is a technique used to assess a mass and is illustrated in the image. Obturator muscle test The obturator muscle test should be performed if the nurse suspects a ruptured appendix or pelvic mass, but is not illustrated in the image. McBurney sign McBurney sign refers to rebound tenderness over McBurney's point in the lower right quadrant which suggests appendicitis, and it is not illustrated in the image. Iliopsoas muscle test The iliopsoas muscle test should be performed if the nurse suspects appendicitis and is not illustrated in the image.

Which elements of a patient's abdomen should be assessed on inspection? Select all that apply. Movement Contour Bowel sounds Skin temperature Surface characteristics

Contour Surface characteristics Movement Rationale: Movement The movement of the abdomen would be assessed on inspection. Correct Contour The contour of the abdomen would be assessed on inspection. Bowel sounds Bowel sounds would be auscultated, not inspected. Skin temperature Skin temperature would be palpated, not inspected. Correct Surface characteristics The surface characteristics of the abdomen would be assessed on inspection.

Which type of palpation is necessary to delineate abdominal organs and detect masses? Light Moderate Deep Bimanual

Deep Rationale: Light Light palpation will not delineate abdominal organs and detect masses. Moderate Moderate palpation will not delineate abdominal organs and detect masses. Deep Deep palpating is necessary to delineate abdominal organs and detect masses. Bimanual Bimanual palpation will not delineate abdominal organs and detect masses.

In which region of the abdomen would the nurse assess to palpate the pancreas? Umbilical Epigastric Left hypochondriac Right inguinal

Epigastric Rationale: Umbilical The nurse would not palpate the pancreas in the umbilical region of the abdomen. Epigastric The nurse would palpate the pancreas in the epigastric region of the abdomen. Left hypochondriac The nurse would not palpate the pancreas in the left hypochondriac region of the abdomen. Right inguinal The nurse would not palpate the pancreas in the right inguinal region of the abdomen.

Over which abdominal region should the nurse auscultate to assess for a venous hum? Umbilical Left hypochondriac Right inguinal Epigastric

Epigastric Rationale: Umbilical The nurse would not auscultate the umbilical region of the abdomen to assess for a venous hum. Left hypochondriac The nurse would not auscultate the left hypochondriac region of the abdomen to assess for a venous hum. Right inguinal The nurse would not auscultate the right inguinal region of the abdomen to assess for a venous hum. Correct Epigastric The nurse would auscultate the epigastric region of the abdomen to assess for a venous hum.

Over which sites should the nurse auscultate to assess for bruits? Umbilical Left hypochondriac Right inguinal Epigastric

Epigastric Rationale: Umbilical The nurse would not auscultate the umbilical region of the abdomen to assess for bruits. Left hypochondriac The nurse would not auscultate the left hypochondriac region of the abdomen to assess for bruits. Right inguinal The nurse would not auscultate the right inguinal region of the abdomen to assess for bruits. Correct Epigastric The nurse would auscultate the epigastric region of the abdomen to assess for bruits.

On auscultation, which elements of a patient's bowel sounds should be assessed? Select all that apply. Frequency Character Number Tone Pitch

Frequency Character Rationale: Frequency The frequency of the bowel sounds should be assessed. Character The character of the bowel sounds should be assessed, including regularity. Number The total number of bowel sounds is not assessed on auscultation. Tone The tone of the bowel sounds is not assessed on auscultation. Pitch The pitch of the bowel sounds is not assessed on auscultation.

Which structure is palpated below the liver margin at the lateral border of the rectus abdominis muscle? Spleen Pancreas Gallbladder Left kidney

Gallbladder Rationale: Spleen The spleen is not palpated below the liver margin at the lateral border of the rectus abdominis muscle. Pancreas The pancreas is not palpated below the liver margin at the lateral border of the rectus abdominis muscle. Correct Gallbladder The gallbladder is palpated below the liver margin at the lateral border of the rectus abdominis muscle. Left kidney The left kidney is not palpated below the liver margin at the lateral border of the rectus abdominis muscle.

How should the nurse assess for ascites in a patient? Select all that apply. Look for a fluid wave Auscultate for fluid Identify shifting dullness on percussion Palpate for a mass Inspect for pulsations

Identify shifting dullness on percussion Look for a fluid wave Rationale: Look for a fluid wave A fluid wave is a specific test to identify ascites. Auscultate for fluid Ascites is not identified through auscultation. Identify shifting dullness on percussion Shifting dullness is indicative of ascites. Palpate for a mass Ascites is not identified through palpation. Inspect for pulsations Ascites is not identified through inspection.

Which test should be performed if the nurse suspects appendicitis? Ballottement Obturator muscle test McBurney sign Iliopsoas muscle test

Iliopsoas muscle test Rationale: Ballottement Ballottement is a technique used to assess a mass, not a test to be performed if the nurse suspects appendicitis. Obturator muscle test The obturator muscle test should be performed if the nurse suspects a ruptured appendix or pelvic mass, not if the nurse suspects appendicitis. McBurney sign McBurney sign refers to rebound tenderness over McBurney's point in the lower right quadrant which suggests appendicitis, but it is not a test that is performed when then nurse suspects appendicitis. Iliopsoas muscle test The iliopsoas muscle test should be performed if the nurse suspects appendicitis.

It is best to determine liver size through percussion by evaluating which characteristics of the liver? Select all that apply. Liver weight Liver tone Liver span Liver circumference Extent of liver projection

Liver span Extent of liver projection Rationale: Liver weight The weight of the liver cannot be percussed. Liver tone The tone heard on percussion of the liver cannot determine liver size. Correct Liver span The nurse should percuss liver span as determined from percussing the upper and lower borders. Liver circumference The circumference of the liver cannot be percussed. Correct Extent of liver projection The nurse should percuss the extent of liver projection below the costal margin.

Which test should be performed if the nurse suspects a ruptured appendix? Ballottement Obturator muscle test McBurney sign Iliopsoas muscle test

Obturator muscle test Rationale: Ballottement Ballottement is a technique used to assess a mass, not a test to be performed if the nurse suspects a ruptured appendix. Obturator muscle test The obturator muscle test should be performed if the nurse suspects a ruptured appendix or pelvic mass. McBurney sign McBurney sign refers to rebound tenderness over McBurney's point in the lower right quadrant which suggests appendicitis, but it is not a test that is performed when then nurse suspects a ruptured appendix. Iliopsoas muscle test The iliopsoas muscle test should be performed if the nurse suspects appendicitis, not a ruptured appendix.

At which abdominal landmark would the nurse begin percussing the spleen? Anterosuperior iliac spine Anterior to the midclavicular line Posterior to the left midaxillary line Right of the xiphoid process of sternum

Posterior to the left midaxillary line Rationale: Anterosuperior iliac spine The nurse would not begin percussing the spleen at the anterosuperior iliac spine. Anterior to the midclavicular line The nurse would begin percussing the spleen anterior to the midclavicular line. Correct Posterior to the left midaxillary line The nurse would begin percussing the spleen posterior to the left midaxillary line. Right of the xiphoid process of sternum The nurse would begin percussing the spleen to the right of the xiphoid process of sternum.

The liver is palpated in the previous slide. (see back for rationale)

Rationale: Kidney The kidney is not being palpated in this image. Liver The liver is being palpated in this image. Spleen The spleen is not being palpated in this image. Lung The lung is not being palpated in this image.

Epigastric

Rationale: Epigastric The epigastric region is assessed in the upper middle region of the abdomen (region 1). Umbilical The umbilical region is in the center of the abdomen (region 2), not the upper middle region. Hypogastric The hypogastric region is in the lower middle region of the abdomen (region 3), not the upper middle region. Left hypochondriac The left hypochondriac region is located in the upper left region of the abdomen (region 4), not the upper middle region.

Kidney (rationale on back) this is the answer to 31

Rationale: Kidney The image shows a nurse palpating the patient's kidney. Pancreas The image does not show a nurse palpating the patient's pancreas. Liver The image does not show a nurse palpating the patient's liver. Stomach The image does not show a nurse palpating the patient's stomach.

Which signs indicate peritoneal inflammation on assessment? Boggy abdomen on palpation Rebound tenderness Dull note on percussion Pulsations on inspection McBurney sign

Rebound tenderness Rationale: Boggy abdomen on palpation Bogginess on palpation does not indicate peritoneal inflammation. Correct Rebound tenderness Rebound tenderness can indicate peritoneal inflammation. Dull note on percussion Dull note on percussion does not indicate peritoneal inflammation. Pulsations on inspection Pulsations on inspection do not indicate peritoneal inflammation. McBurney sign McBurney sign refers to rebound tenderness over McBurney's point in the lower right quadrant which suggests appendicitis, but it does not indicate peritoneal inflammation.

At which abdominal landmark would the nurse begin percussing the liver? Umbilical ring Costal margin Right midclavicular line Superior margin of os pubis

Right midclavicular line Rationale: Umbilical ring The nurse would not begin percussing the liver at the umbilical ring. Incorrect Costal margin The nurse would not begin percussing the liver at the costal margin. Correct Right midclavicular line The nurse would begin percussing the liver at the right midclavicular line. Superior margin of os pubis The nurse would not begin percussing the liver at the superior margin of os pubis.

On palpation, which features of detected masses should be assessed? Select all that apply. Size Shape Pulsation Mobility Surface texture Movement with respiration

Size Shape Pulsation Mobility Movement with respiration Rationale: Size The size of detected masses should be palpated. Correct Shape The shape of detected masses should be palpated. Correct Pulsation The pulsation of detected masses should be palpated. Correct Mobility The mobility of detected masses should be palpated. Incorrect Surface texture The surface texture of detected masses is not palpated. Correct Movement with respiration The movement with respiration of detected masses should be palpated.

Over which abdominal structures should the nurse auscultate for friction rubs? Select all that apply. Heart Spleen Lungs Liver Colon

Spleen Liver Rationale: Heart Friction rubs are not auscultated over the heart. Spleen Friction rubs can be auscultated over the spleen. Lungs Friction rubs are not auscultated over the lungs. Liver Friction rubs can be auscultated over the liver. Colon Friction rubs are not auscultated over the colon.

Which abdominal structures are assessed through percussion? Select all that apply. Spleen Pancreas Liver Kidneys Lungs

Spleen Liver Kidneys Rationale: Spleen The spleen is assessed through percussion. Pancreas The pancreas is not assessed through percussion. Liver Liver span is assessed through percussion. Kidneys Kidney tenderness is assessed through percussion. Lungs The lungs are not assessed through percussion.

Iliopsoas muscle test

This test should be performed if the nurse suspects appendicitis.

Stria or plural striae

a linear mark, slight ridge, or groove on a surface, often one of a number of similar parallel features. ANATOMY any of a number of longitudinal collections of nerve fibers in the brain.

Ballottement

a technique used to assess a mass, not a test to be performed if the nurse suspects appendicitis.