N366 Exam 3- Abdomen and Musculoskeletal

A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining whether this client is truly experiencing an alteration in bowel pattern?

"How many times a day are you having a bowel movement?"

A nurse observes silvery, white 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?"

When assessing muscle tone and strength, the nurse would document expected findings as

"upper and lower extremity muscle strength is 5/5 bilaterally"

How would the nurse document normal muscle strength?

5/5

The normal liver span is ___ to ___ cm

6-12

While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound?

Borborygmus

A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?

Cervical strain--> This can occur from sleeping in the wrong position, carrying a heavy load, or being in an automobile accident.

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 new client is admitted to a long term care facility. The nurse assesses the client with an unsteady gait and incontinence. Which problem should the nurse address when planning care for this client?

Falls

On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity?

Fluid accumulation

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect?

Gouty arthritis

The nurse notes when the client enters the room for the physical examination, there is unsteadiness during the weight-bearing stance phase of walking. Which of the following areas should the nurse focus the assessment?

Hips

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.

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor?

Low estrogen levels

A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?

Measure movement with a goniometer

The nurse assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C (99.3°F;). Which of the following interventions is appropriate for this client?

Monitor pulse and blood pressure every 15 minutes until stable

You are assessing a patient for acute cholecystitis. What sign would you assess for?

Murphy sign

When inspecting a client's feet, the nurse observes that the toes point inward. The nurse documents this finding as which of the following?

Pes varus

To promote relaxation of the client's 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 receives physical therapy for carpal tunnel syndrome. Which action by the nurse is appropriate to assess the efficacy of the treatment?

Place the backs of both hands against each other

he gallbladder, liver, and head of the pancreas are located in what quadrant?

RUQ

When asked to touch the ear to the shoulder, a client reports pain. Which of the following would the nurse do next?

Refer the client for further evaluation.

What finding should a nurse expect when performing the Phalen's test on a client with suspected carpal tunnel syndrome?

Reports of tingling, numbness, and pain in the involved wrist

A change in the color of the fingers from red to white (pale) is seen in clients with

Reynaud's disease.

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?

Right lower quadrant

The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply.

Risk for injury related to osteoporosis Activity intolerance related to osteoporosis Impaired physical mobility related to osteoporosis

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus?

Stop palpating and get medical assistance.

what are normal findings of the abdomen?

Symmetric appearance and absence of bulging when the client raises his head; abdominal respiratory movements

T or F Rovsing's sign is a test of referred rebound tenderness in appendicitis.

T

The nurse is preparing to palpate the client's spleen. What should the nurse instruct the client to do?

Take a deep breath and exhale while lying on his or her back

The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process?

Tenderness

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 nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem?

Visible peristaltic waves

The peritoneum , mesentery, and muscles are all part of the

abdominal cavity

Pain with gastric acid reflux may occur when?

after eating as a brining sensation in esophagus

What does overflow incontinence indicate?

anatomic obstruction by prostatic hypertrophy or stricture, or neurogenic abnormalities.

A prominent pulsating mass in the upper abdomen raises suspicion for what?

and abdominal aortic aneurysm

Borborgymus bowel sounds are

are the loud, prolonged gurgles characteristic of one's "stomach growling."

A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of

arthritis

While assessing the elbow of an adult client, the client complains of pain and swelling. The nurse should further assess the client for

arthritis

Inability to perform active range of motion with the involved wrist and stiffness in the hands and fingers after holding and releasing a tight fist may be seen in clients with

arthritis in the joints.

Flexion is

bending the extremity at the joint and decreasing the angle of the joint.

The liver produces _____ and the gallbladder stores _____

bile; bile

Rheumatoid arthritis

can occur in any joint but usually affects the hands first.

Phalen's test

carpal tunnel syndrome--> lace the backs of both hands against each other while flexing the wrist 90 degrees downwards for 60 seconds

McBurneys point

described as one third of the way between the anterior superior iliac spine and the umbilicus on the right; periumbilical paint hat localizes in the RLQ

Hyperactive bowel sounds may be caused by

diarrhea, gastroenteritis, and early bowel obstruction.

Degenerative joint disease

does not typically cause the joints to be reddened and hot because it is not an inflammatory process.

visceral pain is often described as

dull, aching, burning, cramping, or colicky.

The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant?

dullness--> over the liver

Acute appendicitis would present as ?

fever, nausea, vomiting

An adult client tells the nurse that he eats sardines every day. The nurse should instruct the client that a diet high in purines can contribute to

gouty arthritis.(liver and sardines are examples of foods)

When auscultating what shod a nurse be listening for ?

hums and rubs

urge incontinence

if unable to hold the urine, suggests detrusor overactivity;

Cervical disc degenerative disease is associated with

impaired range of motion and pain that radiates to the back, shoulders, or arms.

Percussion of the spleen begins

in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness

What is stress incontinence due to?

increased intra-abdominal pressure suggests decreased contractility of the urethral sphincter or poor support of bladder neck

What does an increase in peristaltic waves with progression in a ripple like fashion suggest?

intestinal obstruction

The costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a ______ problem

kidney (CVA tenderness)

an increase in the thoracic curvature

kyphosis.

an increase in the lumbar curvature

lordosis

A deviated umbilicus may be caused by pressure from a

mass, enlarged organs, hernia, fluid, or scar tissue.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible

masses

Scale for grading muscle strength

muscle strength is graded on a 0 to 5 scale: 0: No muscular contraction detected 1: A barely detectable flicker or trace of contraction 2: Active movement of the body part with gravity eliminated 3: Active movement against gravity 4: Active movement against gravity and some resistance 5: Active movement against full resistance without evident fatigue. This is normal muscle strength.

An intestinal obstruction would present what type of side effects?

nausaea and vomiting

Cervical spinal cord compression causes

neck pain with loss of sensation in the legs.

Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure?

overflow incontinence

Psoas sign occurs when

pain in the right lower quadrant occurs with raising of the client's right leg from the hip and pressure applied downward against the lower thigh

The obturator sign occurs when

pain in the right lower quadrant results when the client's right knee and ankle are supported and the leg is rotated internally and externally.

Verruca vulgaris are

painful warts that often occur under a callus

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

Absent bowel sounds can be associated with what two disorders

paralytic ileus or peritonitis

Percussion of liver tenderness is elicited by

placing the left hand flat against the lower rib cage and striking it with the ulnar side of the right fist.

Tenderness of the calcaneus of the bottom of the foot may indicate

plantar fasciitis.

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 should document which of the following?

positive rosvings signs

How do you assess for signs of hypovolemia

postural hypotension, poor skin turgor, thirst, sunken eyeballs, and weakness.

Intestinal adhesions would present as what?

pulling in the abdominal regions

Bleeding within the abdominal wall would manifest as

purple discoloration at the flanks.

How do you perform rosvings sign

put pressure on RLQ and if pain present as you release in RLQ then positive suggesting acute appendicitis

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

raise the client's right leg from the hip.--> by asking the client to lie on the left side. Hyperextend the right leg of the client.

The spleen stores

red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes.

Nodules of posterior ankle may be seen with

rheumatoid arthritis

While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible

rotator cuff tear.

In older adults reduction in _____ ________ results in reduced gastric motility and peristalsis

saliva and stomach acid

A client has uneven height of the shoulders and hips. What should the nurse suspect this client is demonstrating?

scoliosis

The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. The nurse suspects that the client is experiencing

scoliosis

The pancreas is responsible for the

secretion of insulin, amylase and lipase.

The subacromial bursae are contained in the

shoulder joint

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant?

spleen

Extension is

straightening the extremity at the joint and increasing the angle of the joint.

Hypoactive bowel sounds may be due to

surgery or late bowel obstruction

A positive hypersensitivity test occurs when the client experiences pain or exaggerated sensation when

the abdomen is stroked with a sharp object.

Hallux valgus is noted as

the great toe deviating laterally and possibly overlapping the second toe.

When muscle loss is symmetrical it is generally due to

the normal aging process.

pain related to gastric ulcers may occur when?

the stomach is emtpy

Pes cavus refers

to feet with high arches.

What are normal percussion sounds one would heard over the LUQ

tympanic notes over gastric bubble

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should

use the diaphragm of the stethoscope.

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

usually difficult to localize

Visible peristaltic waves are typically only visible in what type of people?

very thin people