Health Assessment Ch 20

acute diverticulitis

A 76-year-old retired farmer comes to the office reporting abdominal pain, constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or diarrhea. The only unusual thing he remembers eating was two bags of popcorn at the movies with his grandson 3 days before his symptoms began. He denies any other recent illnesses. His past medical history is significant for coronary artery disease and high blood pressure. He has been married for more than 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon cancer and his father had a stroke. On examination he appears his stated age and is in no acute distress. His temperature is 100.9 degrees; other vital signs are unremarkable. His head, cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable, and his fecal occult blood test is negative. His prostate is slightly enlarged, but his testicular, penile, and inguinal examinations are all normal. Blood work is pending. What diagnosis for abdominal pain best describes his symptoms and signs?

irregular, large liver

A 77-year-old retired bus driver presents at his wife's request to the clinic for a physical examination. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for more than 40 years. He denies any tobacco or drug use and has not drunk alcohol since getting married. His parents both died of cancer in their 60s. On examination his vital signs are in expected ranges. His head, cardiac, and pulmonary examinations are unremarkable. Abdominal examination reveals normal bowel sounds. Results of palpation of the liver are abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination?

positive Rovsing's sign

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. The nurse interprets this as?

referred pain

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?

Crohn's disease

A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause?

gastric ulcer

A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?

internal adhesions from previous surgery

A client presents to the emergency department with reports of new onset of abdominal pain for the past three (3) days. The client states there is also a pulling feeling on the right side. Upon examination the nurse notices a 5cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process?

at the symphysis pubis

A client's bladder is found to be distended. At which location should the nurse begin palpating?

Supply nutritional information to the child, Educate the family about the poor nutritional value of fast food, Supply only healthy foods in the house

A mother is worried about her teenage child's weight. The teenager weighs 80 kg (176 lbs). What can the nurse teach the mother about her child's eating habits?

it is a normal sized liver

A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating?

absent

A nurse examines a client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of the client's abdomen?

right side-lying

A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation?

"How many times have you been pregnant?

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?

Stop the palpation and notify the health care provider

A nurse performs light palpation of the abdomen and feels a prominent, nontender, pulsating mass above the umbilicus that measures approximately 6 cm. What is an appropriate action by the nurse?

liver

A nurse performs percussion by placing the left hand flat against the client's lower rib cage and striking it with the ulnar side of the right fist. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?

suggestive of an enlarged spleen

A palpable spleen is

liver disease

A patient's most recent laboratory results indicate increases in alanine aminotransferase (ALT) and aspartate aminotransferase (AST). What might the nurse suspect is wrong with this patient?

decreased activity of protective bacteria in the urinary tract

An older client presents with symptoms of pain on urinating. The nurse recognizes that older adults are at increased risk for urinary tract infections due to

cholecystitis

Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect?

discrete

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. This would be documented as?

document the position of the liver

During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate?

Stop palpating and get medical assistance

During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take?

Murphy's

During the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign?

obturator

During the abdominal examination, a nurse supports the client's right knee and ankle. The nurse flexes the client's hip and rotates the leg externally and internally. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign?

bleeding from a peptic ulcer

Jim is a 60-year-old man who presents with vomiting. He denies any blood in his emesis, which has been present for 2 days. He does note a dark granular substance resembling the coffee left in the filter after brewing. What should the nurse suspect?

irritable bowel syndrome

Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. What is she most likely experiencing?

enlarged bladder

Mr. Kruger, 84 years old, presents with a smooth lower abdominal mass in the midline, which is minimally tender. There is dullness to percussion up to 6 cm above the symphysis pubis. What does this most likely represent?

jejunum

Nursing students are giving a class presentation on the digestive process. The students would identify villi as being present in what part of the GI tract?

decreased saliva production

Older adults often have trouble with swallowing. What might cause this?

shifting dullness test

On elf the test for ascites is

linea nigra, everted umbilicus, striae

Some changes that appear on the skin of the abdomen as a result of pregnancy are what?

right lower quadrant

The colon originates in this abdominal area: the

6-12 cm

The normal liver span at the right MCL is

inflammation of the gallbladder

The nurse as elicited a positive Murphy sign. The knows this is indicates what?

peritoneal irritation

The nurse assesses an adult male client's abdomen and observes diminished abdominal respiration. The nurse determines that the client should be further assessed for

RUQ

The nurse correctly identifies the gallbladder is located where?

paralytic ileus

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

pressing deeply at the right lower quadrant

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

right lower quadrant

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

tympany

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?

breathe deeply

The nurse is percussing a client's liver and is assessing liver descent. The nurse would have the client do which of the following?

ask the client to breathe deeply and slowly

The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment?

palpate deeply while quickly releasing pressure

The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should

"Before I get ready to examine the painful area, I will let you know in plenty of time."

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?

Deep epigastrium to the left of midline

The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location?

distract the patient with conversation, have the patient mouth breathe with the jaw dropped open, assess relaxation of abdominal muscle after the patient exhales

The nurse notes guarding while palpating the abdomen of a newly admitted patient despite asking the patient to try to relax. The nurse should

costovertebral angle

The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the

not be palpated

The nurse recognizes a vigorous pulsating midline abdominal mass should

produces clotting factors

The nurse understands that the liver does what?

applying and releasing pressure to the abdomen

The nurse would assess for positive Blumberg sign how?

visceral pain

The type of pain felt when hollow abdominal organs become distended or contract forcefully is called

rebound tenderness, the posts sign, and the obturator sign

There are several tests to determine peritoneal irritation that can occur with conditions like appendicitis. The nurse knows these test include

raise the client's right leg from the hip

To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should

RLQ

To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's

place a pillow under the clients knees

To promote relaxation of the client's abdominal muscles, which of the following would be most appropriate for the nurse to do?

usually difficult to localize

Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is

splenomegaly

What should a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?

family history and dietary habits

When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?

bowel sounds normal

When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding?

abdominal aortic aneurysm

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?

right upper

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant?

placing the right hand at the patients right MCL under the costal margin

When palpating the liver, the nurse applies the technique of

empty the bladder, lie supine with arms at the side, distract the patient to avoid the patient tensing the abdominal muscles.

When preparing a patient for an examination of the abdomen, the nurse asks the patient to

A firm, smooth, even surface

When the nurse is able to feel the liver, he/she would expect to feel

large intestine

Where in the digestive tract is most of the water absorbed?

flex the client's legs by placing a pillow under the knees

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?

abdominal pain

Which of the following acute abdominal symptoms could be life threatening?

spleen

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?

intestinal obstruction

While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tingling sounds throughout the distended abdomen. The nurse should refer the client to a physician for possible

borborygmus

While assessing the patients bowel sounds, the nurse hears loud, prolonged gurgles characteristic of a "stomach growling". The nurse documents this as