Chapter 22 Abdomen QUESTIONS

19. A nurse notices that a patient has ascites, which indicates the presence of:

A) fluid. (Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.)

37. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color.The nurse recognizes that the patient may have which condition?

C) Umbilical hernia

3. A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:

C) dysphagia.

21. The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be:

C) gastrointestinal bleeding. (Black stools may be tarry as a result of occult blood [melena] from gastrointestinal bleeding. Red blood in stools occurs with localized bleeding around the anus.)

18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of:

C) kidney inflammation.

5. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:

D) decreased gastric acid secretion.

13. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

D) hyperactive bowel sounds. (Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.)

7. A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as:

D) protuberant.

29. Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?

A) "It should fall off by 10 to 14 days." (At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton jelly. The umbilical stump dries within a week, hardens, and falls off in 10 to 14 days. Skin will cover the area in 3 to 4 weeks.)

34. The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group?

A) African-Americans (A recent study found estimates of lactose-intolerance prevalence as follows: 19.5% for Blacks, 10% for Hispanics, and 7.72% for Whites.)

1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

A) Dullness (The liver is located in the right upper quadrant and would elicit a dull percussion note)

30. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?

A) Dullness across the abdomen

33. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?

A) Spleen (The spleen is located in the left upper quadrant of the abdomen.)

36. During report, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to:

A) an enlarged liver.

24. During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by:

A) projectile vomiting (Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.)

31. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?

B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."

11. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

B) "It prevents distortion of bowel sounds that might occur after percussion and palpation."

27. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:

B) 5 minutes. (Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent.)

14. During an abdominal assessment, the nurse would consider which of these findings as normal?

B) A tympanic percussion note in the umbilical region (Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine)

1. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply

B) Test for Blumberg's sign D) Perform iliopsoas muscle test (Testing for the Blumberg sign [rebound tenderness] and performing the iliopsoas muscle test should be used when assessing for appendicitis.)

28. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?

B) Test for Murphy's sign

23. The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true?

B) The abdominal musculature is thinner. (In the older adult, the abdominal musculature is thinner and has less tone than that of the younger adult)

12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?

B) They are usually high-pitched, gurgling, irregular sounds.

17. An older patient has been diagnosed with pernicious anemia, The nurse knows that this condition could be related to:

B) decreased gastric acid secretion. (Gastric acid secretion decreases with aging and may cause pernicious anemia because it interferes with vitamin B12 absorption iron-deficiency anemia, and malabsorption of calcium.)

20. The nurse knows that during an abdominal assessment, deep palpation is used to determine:

B) enlarged organs. (With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.)

39. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:

B) examine the tender area last.

10. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:

B) peritonitis. (Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.)

15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause:

B) pyrosis. (Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy.)

26. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?

C) A pulsating mass is usually present. (Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.)

22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?

C) Appendix (The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant.)

40. During a health history, the patient tells the nurse, I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms?

C) Duodenal ulcer (Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may relieved by more food.)

9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:

C) normal abdominal aortic pulsations. (Normally, the pulsations from the aorta are observed beneath the skin in the epigastric area, particularly in thin persons who have good muscle wall relaxation.)

16. The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:

C) tympany, hyperresonance, and dullness.

6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

D) An enlarged spleen should not be palpated because it can rupture easily. (If an enlarged spleen is felt, then the nurse should refer the person and should not continue to palpate it. An enlarged spleen is friable and can easily rupture with overpalpation.)

35. The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem?

D) Frequent use of nonsteroidal antiinflammatory drugs

4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

D) Percuss and palpate the midline area above the suprapubic bone. (Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.)

25. To detect diastasis recti, the nurse should have the patient perform which of these maneuvers?

D) Raise the head while remaining supine.

2. Which structure is located in the left lower quadrant of the abdomen?

D) Sigmoid colon

38. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:

D) ascites. (If ascites [fluid in the abdomen] is present, then the examiner will feel a fluid wave when assessing the abdomen.)

8. The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile.

D) concave

32. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should:

D) consider this a normal finding and proceed with the examination. (A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.)