CA CH 23, Ch 23 Abdomen

The nurse is assessing an older adult client who has lost 2.27 kg (5lb) since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for

appetite changes

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

costovertebral angle

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. The priority nursing diagnosis for this client is

disturbed body image related to temporary colostomy

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

"I can decrease the constipation if i eat foods high in fiber and drink water."

Paralytic ileus

Absent or high-pitched bowel sounds

Positive psoas sign

Assessed by raising right leg from hip

The pancreas of an adult client is located

deep in the upper abdomen and is not normally palpable

Ascites

shifting dullness and fluid wave tests

30. The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment? A) Ask the client to breathe slowly and deeply. B) Perform auscultation prior to palpation. C) Explain the procedure to the client before palpating. D) Position the client sitting upright.

A) Ask the client to breathe slowly and deeply.

18. A nurse is reviewing the various causes associated with abdominal distention. Which of the following should the nurse identify? Select all that apply. A) Fat B) Stool C) Gas D) Hernia E) Fibroid tumors

A) Fat B) Stool C) Gas E) Fibroid tumors

8. A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following? A) It is a normal-sized liver. B) The liver is larger than normal. C) It is a smaller-than-normal liver. D) The liver has atrophied.

A) It is a normal-sized liver.

19. 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? A) Positive Rovsing's sign B) Psoas sign present C) Obturator sign positive D) Positive skin hypersensitivity test

A) Positive Rovsing's sign

23. An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide? A) Quit smoking as soon as possible. B) Exercise for at least 30 minutes, three times per week. C) Eat several small meals a day rather than three larger meals. D) Attend screening clinics at least twice per year.

A) Quit smoking as soon as possible.

26. The nurse is assessing the gastrointestinal system of an 81-year-old client. What age- related change should the nurse consider when collecting and analyzing assessment data? A) The client is more vulnerable to impaired nutrition due to decreased appetite. B) The client derives less nutritional value from food because of decreased enzyme production. C) The client's liver will be significantly larger than that of a younger client. D) The client will have greater bowel motility than a younger adult.

A) The client is more vulnerable to impaired nutrition due to decreased appetite.

2. When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication? A) Vitamin supplement with iron B) Nonsteroidal anti-inflammatory drug C) Antidepressant D) Hormone replacement

A) Vitamin supplement with iron

24. A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor? A) Excessive fat and sugar intake B) Overuse of laxatives C) Obesity D) Inadequate abdominal muscle tone

B) Overuse of laxatives

14. A client's bladder is found to be distended. At which location should the nurse begin palpating? A) At the umbilicus B) At the symphysis pubis C) In the right lower quadrant D) In the left lower quadrant

B) At the symphysis pubis

20. 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? A) I'm going to examine the area where you're having pain first to get a better picture of what's going on. B) Before I get ready to examine the painful area, I will let you know in plenty of time. C) You don't need to worry about anything. I will make sure to be very gentle during the exam. D) Since you're having pain in a certain area, I won't have to do a very detailed exam there.

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

11. The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location? A) Midline at the umbilicus B) Deep epigastrium to the left of midline C) Slightly above the suprapubic area D) Between the umbilicus and the symphysis pubis

B) Deep epigastrium to the left of midline

22. A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem? A) Do you feel like you're able to adequately address the stress in your life? B) Do you take painkillers like aspirin on a regular basis? C) Do you tend to eat foods that are quite high in fat? D) Are you currently taking vitamin supplements?

B) Do you take painkillers like aspirin on a regular basis?

7. The nurse is percussing a client's liver and is assessing liver descent. The nurse should have the client do which of the following? A) Cough forcefully B) Hold the breath C) Breathe in and out deeply D) Perform the Valsalva maneuver

B) Hold the breath

9. Which of the following should a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration? A) Hepatomegaly B) Splenomegaly C) Abdominal mass D) Intestinal air

B) Splenomegaly

17. The nurse is assessing a client who is in liver failure and who has developed ascites. When measuring the client's abdominal girth, the nurse should place the client in which position? A) Sitting B) Standing C) Supine D) Prone

B) Standing

Peptic ulcers disease

Bacterium Helicobacter pylori

21. The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon? A) Absorbing electrolytes B) Secreting digestive enzymes C) Absorbing large amounts of water D) Secreting bile

C) Absorbing large amounts of water

5. A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? A) Tenderness on palpation B) Diastasis recti C) Cullen's sign D) Tympany on percussion

C) Cullen's sign

10. While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following? A) Hernia B) Malignancy C) Infection D) Aneurysm

C) Infection

3. A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? A) Palpate, percuss, inspect, auscultate B) Auscultate, inspect, palpate, percuss C) Inspect, auscultate, percuss, palpate D) Percuss, inspect, auscultate, palpate

C) Inspect, auscultate, percuss, palpate

4. To promote relaxation of the client's abdominal muscles, which of the following would be most appropriate for the nurse to do? A) Encourage the client to hold his or her breath. B) Cover the client in a warm blanket. C) Place a pillow under both of the client's knees. D) Assure the client that painful areas will not be examined.

C) Place a pillow under both of the client's knees.

15. 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? A) Right upper quadrant B) Left upper quadrant C) Right lower quadrant D) Left lower quadrant

C) Right lower quadrant

29. The nurse is performing blunt percussion of a client's kidneys. For what abnormal finding is the nurse primarily assessing? A) Dullness B) Tympany C) Tenderness D) Hyperresonance

C) Tenderness

28. The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen? A) Accentuated tympany B) Hyperresonance C) Tympany D) Dullness

C) Tympany

Ballottement test

Can identify a mass or enlarged organ in an ascitic abdomen

6. A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following? A) Normoactive B) Hyperactive C) Hypoactive D) Absent

D) Absent

25. The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. How should the nurse proceed with assessment? A) Review the client's blood work for low platelets and hemoglobin. B) Assess the client for signs and symptoms of fluid volume overload. C) Assess the client's nutritional status. D) Assess the client for other signs and symptoms of liver disease.

D) Assess the client for other signs and symptoms of liver disease.

1. During deep palpation of the client's abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following actions would be most appropriate? A) Refer the client for medical follow-up. B) Evaluate further for a problem with the spleen. C) Assess urinary output. D) Document the position of the liver.

D) Document the position of the liver.

16. The nurse demonstrates the correct technique for assessing the psoas sign by which action? A) Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing B) Tapping fingerpads over the client's abdominal wall, feeling for a floating mass C) Percussing over the client's symphysis pubis with the client supine and then sitting upright D) Flexing the client's right hip, applying downward pressure on the right thigh

D) Flexing the client's right hip, applying downward pressure on the right thigh

27. The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment? A) Repeat auscultation in four to six hours. B) Palpate the client's abdomen to stimulate bowel motility. C) Perform abdominal percussion, wait three to five minutes and then repeat auscultation. D) Listen for at least five minutes before documenting an absence of bowel sounds.

D) Listen for at least five minutes before documenting an absence of bowel sounds.

13. A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation? A) Sitting upright B) Prone C) Semi-Fowler's D) Right side-lying

D) Right side-lying

12. 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? A) Refer the client to an oncologist. B) Provide a dietician consult for the client. C) Counsel the client regarding hernia repair. D) Stop palpating and get medical assistance.

D) Stop palpating and get medical assistance.

Intestinal obstruction

Increased peristaltic waves

Murphy sign

Inspiratory arrest or causes client to hold breath

Hernia

Protrusion of the bowel through the abdominal wall

Cholecystitis

RUQ pain or tenderness

Rebound tenderness

Release of pressure quickly after deep palpation

The abdominal contents are enclosed externally by the abdominal wall musculature-three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external

abdominal oblique

The nurse is planing to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should

ask the client to empty his bladder

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first

inspect the abdominal area

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible

internal bleeding

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

intestinal obstruction

The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that the bowel sounds are not present. The nurse should refer the client to a physician for possible

paralytic ileus

The sigmoid colon is located in this area of the abdomen

left lower quadrant

To palpate the spleen of an adult client, the nurses should begin the abdominal assessment of the client at the

left upper quadrant

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 a possible

masses.

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

palpate deeply while quickly releasing pressure.

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

peritoneal irritation

To palpate the spleen of an adult client, the nurse should

place the right hand below the left coastal margin.

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.

The colon originates in this abdominal area: the

right lower quadrant

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

right lower quadrant

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's

right upper quadrant

The client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of

stomach ulcers

The primary function of the gallbladdr is to

store and excrete bile

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 a possible

umbilical hernia

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.