PrepU ch. 23 assessing abdomen
Sequence the steps of the physical examination of the abdomen in the order the nurse should follow. All options must be used. 1-Drape the client. 2-Ask the client about pain. 3-Warm hands and membrane of the stethoscope. 4-Stand at the client's right side. 5-Begin palpation, auscultation, and percussion.
1-Drape the client. 2-Ask the client about pain. 3-Warm hands and membrane of the stethoscope. 4-Stand at the client's right side. 5-Begin palpation, auscultation, and percussion. Draping the client ensures privacy and makes the client feel more comfortable prior to commencing the physical examination. Asking the client about pain allows the nurse to determine the areas of the physical examination that should be assessed last in order to avoid the client experiencing increased pain throughout the assessment. Warming hands and the membrane of the stethoscope helps promote client comfort. The physical examination should always begin with the nurse at the right side of the client. All these steps allow the nurse to employ the inspection component of the physical examination. Finally, the nurse should engage in the aspect of the physical examination that requires touch. This includes auscultation, palpation, and percussion.
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? a."How many times have you been pregnant?" b."Are you experiencing any abdominal pain?" c."Have you noticed any color change to the skin?" d."Do you have high blood pressure?"
a. "How many times have you been pregnant?" Striae are silvery white marks that are common on the abdomen from stretching of the skin during pregnancy or weight gain. They do not cause pain or any other color changes to the skin. High blood pressure may cause the dilation of the superficial arterioles or capillaries with a central star pattern (spider angioma) but would not result in striae.
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? a.Absent b.Hyperactive c.Borborygmus d.Erratic
a. Absent The nurse should find that bowel sounds are absent in a client with paralytic ileus. Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds. Hyperactive bowel sounds may be caused by diarrhea, gastroenteritis, and early bowel obstruction. Hypoactive bowel sounds may be due to surgery or late bowel obstruction. Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling."
A 27-year-old woman comes to the emergency department reporting severe right lower quadrant pain. Her temperature is 101.5°F (38.6°C), BP 122/80 mm Hg, pulse 95 beats/min, and respirations 22 breaths/min. What might the nurse suspect the client has? a.Acute appendicitis b.Chronic gall bladder disease c.Hepatitis A d.Gastric cancer
a. Acute appendicitis In classic appendicitis, the client reports pain beginning at the umbilicus and moving to the RLQ. If you ask the client to cough, he or she reports pain in the RLQ. The client has local tenderness on palpation in the RLQ, at the McBurney point. A rectal examination, or in women, a pelvic examination, will reveal local tenderness, especially if the appendix is retrocecal.
Which finding obtained during the abdominal assessment in an older adult client should prompt the nurse to perform an additional assessment to determine the cause? a.An enlarged liver felt during palpation b.Report of a decrease in appetite c.Tympany percussed over the stomach d.Negative fluid wave test
a. An enlarged liver felt during palpation The liver normally decreases in size after age 50 years. An enlarged liver needs further assessment. Appetite decreases with age due to altered metabolism, decreased taste sensation, decreased mobility, and possibly depression. Tympany is a normal finding over the stomach. The fluid wave test should be negative unless fluid (ascites) is present in the abdomen.
The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what? a.Bruit b.Borborygmi c.Venous hum d.Friction rub
a. Bruit Bruits are swishing sound that indicate turbulent blood flow. Borborygmi is increased bowel sounds. A venous hum is a soft-pitched humming sound associated with partial obstruction of an artery and reduced blood flow to the organ. Friction rubs are a grating sounds with inspiration.
When palpating a client's abdomen, the nurse notes that the liver has a firm edge. What is the likely cause of his abnormal characteristic? a.Cirrhosis b.Liver failure c.Calcification of the liver d.Splenomegaly
a. Cirrhosis Explanation: A firm hepatic edge is indicative of cirrhosis. A firm edge does not indicate liver failure or calcification. Such an edge is associated with hepatomegaly, not splenomegaly. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 514. Chapter 23: Assessing Abdomen - Page 514
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? a.Crohn's disease b.Gastric ulcer c.Pancreatitis d.Gastroesophageal reflux
a. Crohn's disease Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize? a.Family history; dietary habits b.Dietary habits; social patterns c.Surgical history; family history d.Social patterns; past medical history
a. Family history; dietary habits Poor diet and a family history are both identified as risk factors for colorectal cancer. These aspects of the history would supersede the client's surgical history and social patterns.
Which of the following people need to be vaccinated for hepatitis A and B? a.Food-service workers b.Office personnel c.Truck drivers d.Animal care workers
a. Food-service workers Hepatitis A and B immunizations are recommended for all infants; people whose work may expose them to blood, body fluids, or unsanitary conditions (i.e., health care, food services, sex workers); and those traveling to parts of the world where these illnesses are prevalent.
The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates? a.Inflammation of the gallbladder b.Appendicitis c.Kidney pain d.Peritonitis
a. Inflammation of the gallbladder Explanation: Pain with breathing while assessing Murphy sign is an indication of inflammation of the gallbladder. Peritonitis is assessed for rebound tenderness, indicated by Blumberg sign (a sharp, stabbing pain as the examiner releases pressure from the abdomen). Kidney pain is assessed by performing blunt percussion at the costovertebral angles (CVA). Appendicitis is assessed with the iliopsoas muscle test. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 519. Chapter 23: Assessing Abdomen - Page 519
A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ? a.Kidney b.Liver c.Spleen d.Gallbladder
a. Kidney Explanation: The costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a kidney problem such as infection (pyelonephritis), renal calculi, or hydronephrosis. Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage & striking it with the ulnar side of the right fist. Percussion of the spleen begins in the left mid-axillary line & progresses downward until the sound changes from lung resonance to splenic dullness. The gallbladder is not percussed. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, pp. 494-495. Chapter 23: Assessing Abdomen - Page 494-495
Your client describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your client? a.Malabsorption syndrome b.Lactose intolerance c.Crohn disease d.Ulcerative colitis
a. Malabsorption syndrome Malabsorption syndrome is characterized by stool that is typically bulky, soft, light yellow to gray, mushy, greasy or oily, sometimes frothy, and particularly foul-smelling, and it usually floats in the toilet.
Mr. Martin is a 72-year-old smoker who comes to the clinic for a follow-up visit for hypertension. With deep palpation a pulsatile mass about 4 cm in diameter is palpable. What should the examiner do next? a.Obtain abdominal ultrasound. b.Reassess by examination in 6 months. c.Reassess by examination in 3 months. d.Refer to a vascular surgeon.
a. Obtain abdominal ultrasound. Explanation: A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 cm. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 506. Chapter 23: Assessing Abdomen - Page 506
A nurse assesses a client with a distended abdomen. Which action by the nurse demonstrates the correct way to assess the client for ascites? a.Percuss the flanks from bed upward toward the umbilicus b.Auscultate for bowel sounds in all quadrants of abdomen c.Inspect the abdominal skin for vascularity and striae d.Palpate the abdomen lightly for areas of tenderness
a. Percuss the flanks from bed upward toward the umbilicus Explanation: The nurse should test for shifting dullness by percussing the flanks from bed upward toward the umbilicus to assess for ascites. Auscultating for bowel sounds in all quadrants of abdomen may not give any indication about ascites. Inspecting the abdominal skin for vascularity and striae may indicate ascites but it does not confirm the presence of fluids. Palpating the abdomen lightly for areas of tenderness may not contribute to ascites assessment. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 516. Chapter 23: Assessing Abdomen - Page 516
How should the nurse perform blunt percussion over the liver? a.Place left hand on right lower rib cage, strike it with ulnar side of right fist b.Place right hand on mid of the rib cage; strike it with ulnar side of left fist c.Place left hand on right lower rib cage, strike it with radial side of right fist d.Place right hand on mid of the rib cage; strike it with ulnar side of left fist
a. Place left hand on right lower rib cage, strike it with ulnar side of right fist Explanation: The correct way of performing blunt percussion is to place left hand on right lower rib cage, strike it with ulnar side of right fist. Placing the hand on the mid of rib cage would not enable the nurse to assess the liver. Placing the right hand on the rib cage and striking with radial side of left hand may not be technically possible. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 512. Chapter 23: Assessing Abdomen - Page 512
Which nursing diagnosis is most appropriate for an elderly client with poor dentition? a.Risk for Imbalanced Nutrition: Less Than Body Requirements b.Constipation c.Fluid volume deficit d.Diarrhea
a. Risk for Imbalanced Nutrition: Less Than Body Requirements A client with poor dentition is at risk for Imbalanced Nutrition: Less Than Body Requirements as teeth may be missing or chewing may be difficult. None of the other diagnosis are related to poor dentition.
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? a.Spleen b.Pancreas c.Gallbladder d.Liver
a. Spleen The spleen resides in the abdominal cavity and stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The pancreas resides in the abdominal cavity and is an endocrine gland producing several important hormones, including insulin. The gallbladder, also located in the abdominal cavity, stores bile before it is released into the small intestine. The liver, an organ also located in the abdominal cavity, has a variety of functions to include detoxification, protein synthesis, and the production of biochemical used in the digestion process.
The nurse is assessing the abdomen of a client. While percussing the abdomen, what normal sound does the nurse expect to hear? a.Tympany b.Dullness c.Hollow sound d.Friction rub
a. Tympany Generalized tympany predominates over the abdomen because of air in the stomach and intestines. An enlarged area of dullness would be heard over an enlarged liver or spleen. A friction rub heard over the lower right costal area is associated with hepatic abscess or metastases. A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction, abscess, infection, or tumor. A hollow sound would not be expected at the normal spleen.
The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation? a.identify abdominal organs b.discern muscular resistance c.detect abdominal tenderness d.complete a surface evaluation
a. identify abdominal organs Explanation: Deep palpation is performed to identify abdominal organs. Light palpation is completed to discern muscular resistance, detect abdominal tenderness, and complete a surface evaluation. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 513. Chapter 23: Assessing Abdomen - Page 513
While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tinkling sounds throughout the distended abdomen. The nurse should refer the client to a health care provider for possible... a.intestinal obstruction. b.gastroenteritis. c.inflamed appendix. d.cirrhosis of the liver.
a. intestinal obstruction. Explanation: Obstruction often presents with high-pitched tinkling sounds above the obstruction, in combination with distended abdomen; abdominal cramping is often present as well. Gastroenteritis may present with hyperactive bowel sounds that include tinkling, rushing, and high-pitched sounds and diarrhea is typical, but a distended abdomen is not typical. Cirrhosis of the liver may present with venous hum. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 507. Chapter 23: Assessing Abdomen - Page 507
A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness? a.light palpation b.deep palpation c.percussion d.auscultation
a. light palpation Explanation: Light palpation aids in the detection of abdominal tenderness by allowing palpation without aggravating pain. Deep palpation requires that the nurse press down 5 to 8 cm (2 to 3 inches) which may cause the client further discomfort or pain. Deep palpation is warranted to delineate edges of abdominal organ masses. Percussion helps to assess the amount of gas throughout the abdominal viscera and masses that are solid or fluid filled. Auscultation allows the nurse to listen for bowel sounds. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 504. Chapter 23: Assessing Abdomen - Page 504
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? a.right upper b.left upper c.right lower d.left lower
a. right upper The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal.
During an assessment, the client describes vomiting moderate amounts that "smell like poop." The nurse might suspect... a.small bowel obstruction b.gastric varices c.hypercalcemia d.irritable bowel syndrome
a. small bowel obstruction
The primary function of the gallbladder is to... a.store and excrete bile. b.aid in the digestion of protein. c.produce alkaline mucus. d.produce hormones.
a. store and excrete bile. The gallbladder, a muscular sac approximately 10 cm long, functions primarily to concentrate and store the bile needed to digest fat.
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... a.umbilical hernia. b.ascites. c.intra-abdominal bleeding. d.pancreatitis.
a. umbilical hernia. An enlarged, everted umbilicus suggests umbilical hernia.
Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is... a.usually difficult to localize b.right or left sided c.more severe than parietal pain d.also called referred pain
a. usually difficult to localize Explanation: Visceral pain occurs when hollow abdominal organs, such as the intestines, become distended or contract forcefully, or when the capsules of solid organs such as the liver and spleen are stretched. Poorly defined or localized and intermittently timed, this type of pain is often characterized as dull, aching, burning, cramping, or colicky. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 499. Chapter 23: Assessing Abdomen - Page 499
A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition? a.viral hepatitis b.toxic liver damage c.alcohol hepatitis d.intrahepatic jaundice
a. viral hepatitis Travel to or consuming food meals in an area of poor sanitation can pose a risk for contracting viral hepatitis. This information paired with the client's report of having gray colored stools increases the likelihood of obstructive jaundice related viral hepatitis. Toxic liver damage can result from side effects of certain medications, inhaling or consuming industrial solvents, or exposure to environmental toxins. Alcohol hepatitis is secondary to alcohol abuse. Intrahepatic jaundice arises from damage to the hepatocytes or intrahepatic bile ducts.
The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by... a.Congestive heart failure and pyelonephritis b.Cirrhosis and nephrosis c.Metastatic neoplasms and coronary artery disease d.Congestive heart failure and coronary artery disease
b. Cirrhosis and nephrosis Explanation: Ascites is the accumulation of fluid in the abdomen. The fluid descends with gravity, resulting in dullness to percussion in the lowest point of the abdomen based on client position. Changing the client's position should move the fluid shift to the most dependent point. Ascites occurs in cirrhosis of the liver, congestive heart failure, nephrosis, peritonitis, and metastatic neoplasms. The other options are distracters to the question. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 505. Chapter 23: Assessing Abdomen - Page 505
A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client? a.Ineffective Nutrition: Less Than Body Requirements b.Constipation related to decrease in fluid intake c.Ineffective Health Maintenance d.Risk for Fluid Volume Deficit
b. Constipation related to decrease in fluid intake The nurse can confirm constipation because the major defining characteristics of decreased frequency and abdominal discomfort are present. A few days of altered nutrition does not meet the necessary criteria to confirm Ineffective Nutrition or Risk for Fluid Volume Deficit. Ineffective Health Maintenance cannot be confirmed because there is no evidence that the client lacks the knowledge to eat properly.
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? a.Bleeding b.Fluid accumulation c.Inflammation d.Obstruction
b. Fluid accumulation Pale and taut skin indicates significant abdominal swelling caused by accumulation of fluid in the abdominal cavity, or ascites. Bleeding within the abdominal wall would manifest as purple discoloration at the flanks. Inflammation of the peritoneum and obstruction of the intestine does not contribute to pale and taut abdominal skin.
A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause? a.Crohn's disease b.Gastric ulcer c.Pancreatitis d.Gastroesophageal reflux
b. Gastric ulcer Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.
What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen? a.Epigastric b.Hypogastric c.Hypochondriac d.Inogastric
b. Hypogastric The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right inguinal, hypogastric, and left inguinal.
A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test? a.Obturator b.Murphy's c.Psoas d.Rovsing's
b. Murphy's The gallbladder is located in the right upper quadrant of the abdomen. When it is inflamed (cholecystitis), performing the Murphy's sign will cause the client to hold the breath (inspiratory arrest). The Obturator & Psoas tests are to determine if the appendix is inflamed. Rovsing's sign test for rebound tenderness which may indicate peritoneal irritation.
The client would complain of pain in what quadrant if experiencing appendicitis? a.RUQ b.RLQ c.LUQ d.LLQ
b. RLQ With appendicitis, the client would experience pain in the RLQ.
Which of the following statements provides the most accurate guide to the assessment of the gallbladder? a.The gallbladder should be percussed and palpated prior to the liver to avoid confusing it with the larger organ. b.The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. c.Cholecystitis and cholelithiasis are not amenable to diagnosis in the clinical setting. d.The margins of the gallbladder are obscured by the spleen.
b. The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Because the gallbladder is deep to the liver, it is normally not amenable to direct examination by auscultation, palpation, or percussion. This does not mean, however, that cholecystitis and cholelithiasis cannot be assessed for a thorough history. The gallbladder and the spleen are not proximate.
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? a.This area should be avoided completely b.The left lower quadrant is palpated last c.Medicate for pain before beginning the assessment d.Encourage the client to relax to minimize pain
b. The left lower quadrant is palpated last The nurse should avoid touching tender or painful areas until last and reassure the client. The area needs to be assessed for the presence of abnormal findings and should not be avoided. Medicating before palpating may obscure the findings. The client may not be able to relax just by the power of suggestion.
During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document this finding? a.relieving factors b.associated manifestations c.characteristic symptoms d.onset
b. associated manifestations Explanation: The nurse should document this finding in the associated manifestations section because this is a report on the experience of other symptoms associated with abdominal pain. In relieving factors, the nurse explores factors that aggravate or relieve the pain. In characteristic symptoms, the nurse should ask the client to describe the pain in his or her own words. Onset refers to when the abdominal pain started. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 496. Chapter 23: Assessing Abdomen - Page 496
The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area? a.percussion b.auscultation c.light palpation d.deep palpation
b. auscultation Explanation: Auscultate the abdomen before performing percussion or palpation because these maneuvers may alter the frequency of bowel sounds. After auscultation, the order of assessment should be percussion, light palpation, and conclude with deep palpation. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 502. Chapter 23: Assessing Abdomen - Page 502
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the... a.left lower quadrant. b.left upper quadrant. c.right upper quadrant. d.right lower quadrant.
b. left upper quadrant. The spleen is located in the left upper quadrant.
To palpate the spleen of an adult client, the nurse should... a.ask the client to exhale deeply. b.place the right hand below the left costal margin. c.point the fingers of the left hand downward. d.ask the client to remain in a supine position.
b. place the right hand below the left costal margin. Explanation: To palpate the spleen stand at the client's right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the client's head. Ask the client to inhale and press inward and upward as you provide support with your other hand. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 515. Chapter 23: Assessing Abdomen - Page 515
The nurse would assess for positive Blumberg sign how? a.Applying blunt pressure that the midclavicular line (MCL) b.Applying blunt pressure at the costovertebral angle (CVA) c.Applying and releasing pressure to the abdomen d.Having the client breathe deeply
c. Applying and releasing pressure to the abdomen Pain that occurs after applying and releasing pressure to the abdomen would be a positive Blumberg sign. Murphy sign occurs when the client holds his breath and there is pain. Blunt pressure at the CVA assesses for kidney pain. Liver span test occurs at the MCL.
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? a.Absent b.Hypoactive c.Borborygmus d.Erratic
c. Borborygmus The nurse should find that bowel sounds are absent in a client with paralytic ileus. Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds. Hyperactive bowel sounds may be caused by diarrhea, gastroenteritis, and early bowel obstruction. Hypoactive bowel sounds may be due to surgery or late bowel obstruction. Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling." Erratic is not a type of bowel sound.
The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain? a.Discomfort b.Dysphagia c.Dyspepsia d.Odynophagia
c. Dyspepsia For more chronic symptoms, dyspepsia is defined as chronic or recurrent discomfort or pain centered in the upper abdomen.
A 46-year-old former salesman presents to the ER complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. Examination shows a man appearing older than his stated age. His skin has a yellowish tint and he is thin with a prominent abdomen. Multiple "spider angiomas" are at the base of his neck. Otherwise his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs? a.Infectious diarrhea b.Mallory-Weiss tear c.Esophageal varices
c. Esophageal varices Explanation: Varices are often found in clients with alcoholism, but only when they have a diagnosis of significant cirrhosis. This client has symptoms of cirrhosis including jaundice, ascites, spider hemangiomas, and dilated veins noted on his abdomen (caput medusa). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 499. Chapter 23: Assessing Abdomen - Page 499
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? a.Secretory infections b.Inflammatory infections c.Irritable bowel syndrome d.Malabsorption syndrome
c. Irritable bowel syndrome Irritable bowel syndrome will cause loose bowel movements with cramps, but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely found in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse as well as certain foods.
A nurse receives an order to measure the abdominal girth daily on a client admitted with ascites. How should the nurse best implement this order? a.Have the client lying down in the bed with the head of bed slightly elevated b.Any time of day is acceptable when using the umbilicus as a starting point c.Measure at the same time each day, ideally in the morning after voiding d.Elevate the head of bed to concentrate the fluid in one area of the abdomen
c. Measure at the same time each day, ideally in the morning after voiding The umbilicus should be used as the starting point for measuring abdominal girth, especially when ascites is present. Measure the girth at the same time each day, ideally after the client voids in the morning. The ideal position is for the client to stand. If the client cannot stand, the supine position is acceptable. The head of bed should be flat unless the client has difficulty breathing.
You are assessing a client for acute cholecystitis. What sign would you assess for? a.Psoas sign b.Obstipation sign c.Murphy sign d.Cutaneous hyperesthesia
c. Murphy sign A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.
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? a.Obturator b.Psoas c.Murphy's d.Rovsing's
c. Murphy's Murphy's sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. The obturator sign involves pain in the right lower quadrant as a result of the nurse flexing the client's hip and rotating the leg externally and internally while supporting the client's right knee and ankle. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.
A client reports the onset of pain in the left upper quadrant of the abdomen with the ingestion of alcohol. The nurse recognizes that alteration in function of which organ is most likely to be the cause of this pain? a.Gallbladder b.Kidney c.Pancreas d.Spleen
c. Pancreas Explanation: The pancreas is most likely to be the cause of the pain in the left upper quadrant with ingestion of alcohol because chronic use causes inflammation of this organ. The gallbladder is in the right upper quadrant. The kidney and spleen are not affected by alcohol ingestion. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 499. Chapter 23: Assessing Abdomen - Page 499
The nurse is caring for a female client during her first postoperative day after a temporary colostomy. The client refuses to look at the colostomy bag or the area. A priority nursing diagnosis for this client is... a.denial related to temporary colostomy. b.fear related to potential outcome of surgery. c.disturbed body image related to temporary colostomy. d.altered role functioning related to frequent colostomy bag changes.
c. disturbed body image related to temporary colostomy. Certain GI disorders and their effects (e.g., weight loss) or treatment (e.g., drugs, surgery) may produce physiologic or anatomic effects that affect the client's perception of self, body image, social interaction and intimacy, and life. Disturbed body image related to temporary colostomy would be the most appropriate nursing diagnosis for this client.
To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should... a.rotate the client's knee internally. b.palpate at the lower right quadrant. c.raise the client's right leg from the hip. d.support the client's right knee and ankle.
c. raise the client's right leg from the hip. Explanation: Assess for psoas sign by asking the client to lie on the left side. Hyperextend the right leg of the client. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 518. Chapter 23: Assessing Abdomen - Page 518
During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should... a.palpate the abdomen before auscultation. b.listen in each quadrant for 15 seconds. c.use the diaphragm of the stethoscope. d.begin auscultation in the left upper quadrant.
c. use the diaphragm of the stethoscope. Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client's abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants.
A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says... a."I can decrease the constipation if I eat foods high in fiber and drink water." b."I should cut down on the number of iron tablets I am taking each day." c."Constipation should decrease if I take the iron tablets with milk." d."I should discontinue the iron tablets and eat foods that are high in iron."
d. "I can decrease the constipation if I eat foods high in fiber and drink water." High iron intake may lead to chronic constipation.
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? a.Peptic ulcer b.Cholecystitis c.Pancreatitis d.Appendicitis
d. Appendicitis This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.
An older client presents with symptoms of pain on urinating. The nurse recognizes that older adults are at increased risk for urinary tract infections for which of the following reasons? a.Inadequate hydration b.Poor nutrition c.Higher fat-to-lean muscle ratio d.Decreased activity of protective bacteria in the urinary tract
d. Decreased activity of protective bacteria in the urinary tract Explanation: Older adult clients are prone to urinary tract infections because the activity of protective bacteria in the urinary tract declines with age. It is not established that older adults have poorer hydration or nutrition than younger adults. A higher fat-to-lean muscle ratio would not affect risk for urinary tract infections. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 498. Chapter 23: Assessing Abdomen - Page 498
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? a.Staphylococcus aureus b.Escherichia coli c.Streptococcus pyogenes d.Helicobacter pylori
d. Helicobacter pylori Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucous, on occasion the H. pylori disrupt the mucous lining and inflame the organ lining. The other bacteria listed are not associated with peptic ulcer disease.
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. Which of the following is most likely? a.Colon cancer b.Cholecystitis c.Inflammatory bowel disease d.Irritable bowel syndrome
d. Irritable bowel syndrome Explanation: Although colon cancer should be a consideration, these symptoms are intermittent and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely, especially given that she is a young woman. This very common condition can be triggered by certain foods and stress. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen.
Where in the digestive tract is most of the water absorbed? a.Stomach b.Duodenum c.Ileum d.Large intestine
d. Large intestine Explanation: Any food particles not absorbed by the small intestine pass into the large intestine, where a few electrolytes and water are further absorbed. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 495. Chapter 23: Assessing Abdomen - Page 495
A nurse cares for a client with a duodenal ulcer. The nurse knows that which characteristic of pain is generally associated with the client's condition? a.Increased by intake of food b.Relieved by drinking water c.Throbbing in nature d.May awaken the client at night
d. May awaken the client at night A client with duodenal ulcers would have severe pain that awakens him at night. The pain may not increase by the intake of food but may be relieved by it. The pain is unrelated to drinking water. The nature of the pain may vary and may not necessarily be throbbing.
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? a.Assist the client to the bathroom to empty the bladder b.Use percussion to determine the solidity of the structure c.Auscultate over the same area for the presence of a bruit d.Stop the palpation and notify the health care provider
d. Stop the palpation and notify the health care provider Explanation: A pulsating abdominal mass may indicate the presence of an abdominal aortic aneurysm. An aneurysm is an area within a vessel where the wall of the vessel becomes weak, engorged with blood, and may rupture. The nurse should stop palpating immediately and notify the health care provider. This client may need to go to surgery for repair of the aneurysm. All other options are not safe or indicated for this client at this time. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 514. Chapter 23: Assessing Abdomen - Page 514
When inspecting the abdomen, which of the following client positions facilitates correct examination technique? a.Sitting with hands on hips b.Trendelenburg with hands over head c.Semi-Fowler's with pillows under head and knees d.Supine with arms at sides or folded across chest
d. Supine with arms at sides or folded across chest A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenburg, or semi-Fowler's position.
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites? a.Bilateral flank tympany b.Dullness that remains despite change in position c.Dullness centrally when the client is supine d.Tympany that changes location with client position
d. Tympany that changes location with client position Explanation: A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float, so dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany that changes location with client position ("shifting dullness") would support the presence of ascites. A fluid wave and edema would support this diagnosis as well. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 516. Chapter 23: Assessing Abdomen - Page 516
The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the... a.right upper quadrant. b.left upper quadrant. c.external oblique angle. d.costovertebral angle.
d. costovertebral angle. Kidney tenderness is best assessed at the costovertebral angle.
The pancreas of an adult client is located... a.below the diaphragm and extending below the right costal margin. b.posterior to the left midaxillary line and posterior to the stomach. c.high and deep under the diaphragm and can be palpated. d.deep in the upper abdomen and is not normally palpable.
d. deep in the upper abdomen and is not normally palpable. Explanation: The pancreas, located mostly behind the stomach deep in the upper abdomen, is normally not palpable. It is a long gland extending across the abdomen from the RUQ to the LUQ. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 494. Chapter 23: Assessing Abdomen - Page 494
While auscultating rushes of high-pitched bowel sounds a client complains of abdominal pain. What should the nurse suspect is occurring with this client? a.ileus b.diarrhea c.peritonitis d.intestinal obstruction
d. intestinal obstruction Explanation: Rushes of high-pitched sounds coinciding with an abdominal cramp indicate intestinal obstruction. Bowel sounds are increased in diarrhea. Bowel sounds may be decreased and then absent in ileus and peritonitis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 507. Chapter 23: Assessing Abdomen - Page 507
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... a.gallbladder disease. b.cachexia. c.kidney trauma. d.masses.
d. masses. Explanation: A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 505. Chapter 23: Assessing Abdomen - Page 505
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should... a.perform this abdominal assessment first. b.ask the client to assume a side-lying position. c.palpate lightly while slowly releasing pressure. d.palpate deeply while quickly releasing pressure.
d. palpate deeply while quickly releasing pressure. Explanation: If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen away from the painful or tender area. Then suddenly release pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Assessing Abdomen, p. 518. Chapter 23: Assessing Abdomen - Page 518
To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's... a.left upper quadrant. b.left lower quadrant. c.right upper quadrant. d.right lower quadrant.
d. right lower quadrant. The appendix is located in the right lower quadrant.
