ATI Health Assess 2.0: Abdomen post quiz

which equipment should the nurse use?

- Stethoscope is correct. The nurse should use a stethoscope to auscultate the client's abdominal area to listen for bowel and vascular sounds. Watch is correct. The nurse should use a watch or clock to time the intervals of bowel sounds detected. - Tape measure is correct. The nurse should use a tape measure to measure the client's abdominal circumference if their abdomen is distended. - Reflex hammer is incorrect. A reflex hammer is used to test a client's stretch and deep tendon reflexes. The reflex hammer stimulates the client's muscle by directing a blow of the hammer to the client's tendon of the muscle. - Tuning fork is incorrect. A tuning fork is used to test a client's hearing. The tuning fork can be placed at the center of the back of the client's head to test hearing (Weber test) or placed to each ear (Rhine test).

A nurse is preparing to obtain information regarding a client's abdominal health history. Which of the following questions should the nurse ask

- "Are you experiencing abdominal pain?" is correct. The nurse should ask the client to locate the pain, describe it, rate the intensity of the pain on a scale from 0 to 10, and report how long they have been experiencing the pain. - "Do you take any medication?" is correct. The nurse should ask the client about any medications they are taking because medications can affect a client's abdomen, such as distention, discomfort, nausea or vomiting. - "Have you noticed a change in your appetite?" is correct. This can confirm weight loss or gain along with irritation of the bowel if the client is experiencing decreased hunger, nausea, or vomiting. - "When was your last bowel movement?" is correct. This allows the nurse to collect information on the client's bowel habits. The nurse can also ask about color and consistency of the client's stool at this time. The nurse can also ask about color and consistency of the client's stool at this time. - "Have you had any changes in your urinary output?" is incorrect. The nurse should ask about urinary output when obtaining information regarding the client's urinary system.

A nurse is preparing to inspect a male client's abdomen. Which of the following findings should the nurse identify as an unexpected finding?

- Eversion of the umbilicus is correct. The nurse should identify that eversion of the umbilicus is an unexpected finding when inspecting a client's abdomen, which can indicate conditions such as an abdominal mass or obesity. - Purple striae is correct. The nurse should identify that purple striae is an unexpected finding when inspecting a client's abdomen, which can be an indication of weight gain or loss, abdominal distention, or a manifestation of Cushing syndrome. - Rash is correct. The nurse should identify that a rash is an unexpected finding when inspecting a client's abdomen, which can be an indication of an allergic reaction or a manifestation of a condition the client may have. - Healed scars is incorrect. The nurse should identify that healed scars are an expected finding when inspecting a client's abdomen. - Mole is incorrect. The nurse should identify that a mole (nevi) is an expected finding when inspecting a client's abdomen.

list the steps of light palpation

- Place the client's arms at their sides is the first step. If the client's arms are above their head, it may cause tightness of the abdominal muscles. - Use the finger pads of one hand to palpate is the second step. The pads of all four fingers on one had should be used for light palpation. - Depress the client's abdomen using a dipping motion is the third step. The nurse should depress the abdomen 1 cm (0.4 in) in a dipping motion while performing light palpation. - Move fingers across the client's abdomen moving clockwise is the fourth step. The nurse should move clockwise while assessing the abdomen. - Palpate painful areas is the fifth step. This prevents pain and muscle rigidity during the entire examination.

educating a client to prevent constipation

- "Limit vegetables to 10% of your daily intake." Adults should consume 2 to 3 servings of vegetables daily. - "Drink 32 ounces of water per day." The nurse should instruct the client to drink 8 to 10 glasses of water daily. - "Eliminate legumes from your diet." Legumes are high in fiber and the client should be encouraged to include them in their diet. - "Consume foods that are high in whole grains." The nurse should instruct the client to consume foods that are high in whole grains, such as high-fiber cereals and legumes.

A nurse is auscultating a client's abdomen for the presence of bowel sounds. Which of the following findings should the nurse expect for hypoactive bowel sounds?

- Bowel sounds absent after 5 min Bowel sounds absent after 5 min can indicate an intestinal obstruction. - Bowel sounds auscultated every 5 to 30 seconds Bowel sounds auscultated every 5 to 30 seconds are normoactive bowel sounds. - Bowel sounds auscultated every 3 seconds Bowel sounds auscultated every 3 seconds are hyperactive bowel sounds, also known as "borborygmus." - Bowel sounds heard after 2 min The nurse should identify that hypoactive bowel sounds are auscultated after 1 min and up to 5 min for presence of bowel sounds. This can be related to decreased peristalsis due to constipation, adverse effects of medication, anesthesia, or an intestinal obstruction.

A nurse is preparing to inspect a client's abdomen who has liver disease. Which of the following manifestations should the nurse expect?

- Dilated veins The nurse should identify that dilated veins and spider angiomas on the client's abdomen are manifestations of liver disease. - Stretch marks Stretch marks (silver striae) on the client's abdomen are a manifestation of a previous pregnancy. - Purple striae Purple striae on a client's abdomen is a manifestation related to weight gain or loss, abdominal distention, or Cushing syndrome. - Rash A rash on the client's abdomen is a manifestation related to an allergic reaction or a condition the client may have.

screening prevention for colorectal cancer

- Fecal occult test is correct. A fecal occult test screens for blood in the stool, which can detect ulceration in the colon. - Flex sigmoidoscopy is correct. A flex sigmoidoscopy is performed to visualize the rectum and descending colon. - Colonoscopy is correct. A colonoscopy is performed to visualize the rectum and large intestines. - Barium enema with contrast is correct. A barium enema with contrast is performed to visualize the large intestines using x-ray and contrast dye. - Bronchoscopy is incorrect. A bronchoscopy is performed to visualize the larynx, bronchi, trachea, and alveoli.

The nurse is providing dietary teaching to a client about the purpose of incorporating fiber in their diet. Which of the following information should the nurse include?

- Fiber can be found in most dairy products. Dairy is not an adequate source of fiber. The nurse should encourage the client to consume fiber by eating whole grains, fruits, and vegetables. - Fiber allows larger stool to soften and pass easier. Fiber absorbs water in the intestinal tract, which allows larger stool to soften and pass more easily. - Fiber decreases peristalsis to prevent diarrhea. Fiber increases peristalsis, which prevents constipation. - Fiber promotes the growth of good bacteria in the intestinal tract. Probiotics promote the growth of good bacteria in the intestinal tract to balance with the bad bacteria. This can relieve intestinal discomfort, such as diarrhea or constipation.

A nurse is preparing to auscultate a client's abdomen. which of the following should the nurse expect if the client is experiencing borborygmus?

- Hypoactive bowel soundsHypoactive bowel sounds are sounds that occur for less than 1 min and can be due to impaired peristalsis, medication, constipation, anesthesia, or a bowel obstruction. - Absent bowel soundsThe absence of bowel sounds after 5 min can be an indication that the client has an intestinal obstruction. Another nurse should listen to validate this assessment finding before notifying the provider. - Hyperactive bowel sounds The nurse should identify that borborygmi bowel sounds are hyperactive bowel sounds that are auscultated about every 3 sec due to increased peristalsis of the bowels, as with diarrhea. Borborygmi bowel sounds are louder and have a rushing, rumbling, or tinkling sound. - Normoactive bowel sounds Normoactive bowel sounds are high-pitched, gurgling sounds that occur 5 to 30 times per min.

A nurse is preparing to palpate a client's abdomen. Which of the following findings should the nurse expect?

- Involuntary rigidity Involuntary rigidity can be present when the client's abdomen feels boardlike, hardness, pain, or muscle rigidity, and can be an indication that the client has an abdominal mass or an acute inflammation of the peritoneum. - Voluntary guarding Voluntary guarding can be present if the client is ticklish or cold. The nurse should place the client's hand underneath theirs to palpate the abdomen because clients are not ticklish upon their own touch. - Boardlike Boardlike, hardness, pain, and muscle rigidity can be indications that the client has a mass or an acute inflammation of the peritoneum. - Nontender The nurse should expect the client's abdomen to be nontender, and muscles relaxed upon palpation.

A nurse is preparing to asses a client's abdomen. upon palpation which of the following findings should the nurse report to the provider?

- Nontender The nurse should expect the client's abdomen to be nontender and muscles relaxed upon palpation. - Involuntary rigidity Involuntary ridigity might be present when the client's abdomen feels boardlike, hardness, or pain along with muscle rigidty. This could be an indication that the client has an abdominal mass or an acute inflammation of the peritoneum, and should be reported to the provider. - Relaxed muscles The nurse should expect the client's abdominal muscles to be relaxed and nontender upon palpation. - Adipose tissue The nurse should expect the abdomen of a client who is overweight to have adipose tissue.

A nurse is teaching a client about the purpose of probiotics and incorporation them into their diet. Which of the following information should the nurse include?

- Probiotics increase peristalsis to prevent constipation. Exercise increases peristalsis to prevent constipation. Exercise should be performed for 30 min daily to be effective. - Probiotics allow larger stool to soften to pass. Fiber absorbs water in the intestinal tract which allows larger stool to soften and pass more easily. - Probiotics promote the growth of good bacteria in the client's intestinal tract. The nurse should include that probiotics promote the growth of good bacteria in the intestinal tract to balance with the bad bacteria. This can relieve intestinal discomfort, such as diarrhea or constipation. - Probiotics remove fats and waste products from the body. A diet high in fiber creates a consistent pattern of peristalsis, which removes fats and waste products from the body.

which quadrants should the nurse listen to first?

- Right lower quadrant According to evidence-based practice, the nurse should first auscultate the client's right lower quadrant to determine the presence of bowel sounds. The presence of bowel sounds is typically found in the right lower quadrant, which is located at the ileocecal valve because bowel sounds are transmitted through the abdomen. - Left lower quadrant The nurse should auscultate the presence of bowel sounds in the left lower quadrant. However, evidence-based practice indicates that the nurse should take a different action first. - Right upper quadrant The nurse should auscultate the presence of bowel sounds in the right upper quadrant. However, evidence-based practice indicates that the nurse should take a different action first. - Left upper quadrant The nurse should auscultate the presence of bowel sounds in the left upper quadrant. However, evidence-based practice indicates that the nurse should take a different action first.

A nurse is preparing to inspect a client's abdomen. Which of the following variations should the nurse expect to find.

- Silver striae is correct. The nurse should identify that silver striae is an expected finding when inspecting a client's abdomen, which can be an indication of a previous pregnancy. - Rash is incorrect. The nurse should identify that a rash is an unexpected finding when inspecting a client's abdomen, which can be an indication of an allergic reaction or a manifestation of a condition the client may have. - Taut skin is incorrect. The nurse should identify that taut skin is an unexpected finding when inspecting a client's abdomen, which can be an indication of an ascites. - Healed scars is correct. The nurse should identify that healed scars are an expected finding when inspecting a client's abdomen. - Mole is correct. The nurse should identify that a mole (nevi) is an expected finding when inspecting a client's abdomen.

A nurse is preparing to inspect the umbilicus of a clients abdomen. Which of the following findings should the nurse id as an unexpected finding?

- Swelling The nurse should identify that swelling of the umbilicus can be an indication of a hernia, which is a protrusion of the abdominal viscera through an abnormal opening in the client's muscle wall. - Mole A mole (nevi) on the umbilicus is an expected finding when inspecting the umbilicus of the client's abdomen. - Extraversion Extraversion (pushing upward) of the umbilicus, related to pregnancy, is an expected finding when inspecting the umbilicus of the client's abdomen. - Scar A scar on the umbilicus can be related to a previous surgery, which is an expected finding when inspecting the umbilicus of the client's abdomen.