Chapter 21 Abdomen
The pediatric nurse is preparing an educational presentation for parents of school-aged children regarding hepatitis. Based on the pediatric risk, which type of hepatitis virus will the nurse focus on during the educational session? 1. Hepatitis A virus. 2. Hepatitis B virus. 3. Hepatitis C virus. 4. Hepatitis D virus.
Correct Answer: 1 Hepatitis A occurs most frequently in children and young adults. Hepatitis B, C, and D virus transmission seems unrelated to specific age groups and is most closely associated with specific risk factors or behaviors.
The client states, "No one will let me eat or drink anything until after my test and it's been 9 hours since I last ate anything!" While auscultating the client's abdomen the nurse hears frequent bowel sounds. How will the nurse document this finding in the medical record? 1. Borborygmi present. 2. Hypoactive bowel sounds present. 3. Bruit present. 4. Friction rub present.
Correct Answer: 1 Normal bowel sounds occur every 5 to 15 seconds. Borborygmi are hyperactive bowel sounds that are most often auscultated in clients who have not eaten recently. Hypoactive bowel sounds are most often auscultated in clients who have had abdominal surgery or who have a bowel obstruction. A bruit is a pulsing, blowing sound that can be auscultated over arteries. A friction rub is a rough, grating sound caused by the rubbing together of organs or an organ rubbing on the peritoneum.
The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back. The client states, "This has been happening more often after I eat rich, high-fat foods." Which disorder does the nurse suspect based on these findings? 1. Cholecystitis. 2. Duodenal ulcer. 3. Gastritis. 4. Pancreatitis.
Correct Answer: 1 Right upper quadrant pain that radiates to the right scapula is characteristic of cholecystitis. The pain usually occurs after the client eats a fatty meal. Duodenal ulcers cause aching, gnawing, and epigastric pain, and are associated with stress and NSAID use. Gastritis causes epigastric pain, and is associated with NSAID use, alcohol abuse, stress, infection, H. pylori infection, and autoimmune responses. Pancreatitis produces upper abdominal, knifelike, deep epigastric or umbilical area pain, and is associated with alcohol abuse, use of acetaminophen, and infection.
The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse notes that the liver span is approximately 11 centimeters. How will the nurse document this finding in the medical record? 1. Hepatomegaly. 2. A normal finding. 3. Related to recent diagnosis of chronic bronchitis. 4. Presence of ascites.
Correct Answer: 1 The liver span is the distance between the lower and upper border of the liver. It should be approximately 4 to 9 centimeters (2 to 4 inches). The liver in this situation is not enlarged, and it would be inappropriate for the nurse to determine that client has an enlarged liver (hepatomegaly). The client with chronic bronchitis may have a liver that is displaced downward within the abdomen. The client with ascites may have a liver that is displaced upward within the abdomen.
The nurse is palpating the right upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply. 1. Liver. 2. Gallbladder. 3. Appendix. 4. Spleen. 5. Stomach.
Correct Answer: 1, 2 The liver and gallbladder are located in the right upper quadrant. The appendix is located in the right lower quadrant. The spleen and stomach are located in the left upper quadrant.
The nurse is interviewing an older adult Hispanic client who complains of recent weight loss, anorexia, and epigastric pain. The client reports recent use of "mints" for stomach upset. Based on this assessment data, which interventions are appropriate for this client? Select all that apply. 1. Schedule the client for an endoscopy as ordered. 2. Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider. 3. Educate the client regarding Helicobacter pylori infections. 4. Discuss the importance of using over-the-counter aspirin for mild pain relief. 5. Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer.
Correct Answer: 1, 2, 3 The client should be scheduled for an endoscopy as ordered by the healthcare provider. This is a common diagnostic test used for clients with suspected peptic ulcers. The client should take antacids after meals and at bedtime. The client should be educated about the most common cause of peptic ulcers, which is an infection due to Helicobacter pylori (H. pylori). H. pylori is a bacteria that results in an infection that causes more than 90% of peptic ulcers. It infects almost two thirds of the world's population and is more prevalent in the elderly, African Americans, Hispanics, and those in lower socioeconomic groups. The client should avoid aspirin products because they can make the symptoms worse. The client can avoid spicy foods, but not because this is the most common cause of peptic ulcers; the spicy foods may aggravate the client's condition. In the past, it was believed that ulcers were caused by stress or eating too much acidic food. Now it is known that this is not true.
The nurse is performing an abdominal assessment on a client. During the focused interview, the client tells the nurse about experiencing some abdominal pain recently. As the nurse assesses the client, which behaviors indicate that the client may be experiencing pain or anxiety during the examination? Select all that apply. 1. The client's respiratory rate is 26 per minute. 2. The client moves away from the nurse's hands. 3. The client grimaces. 4. The client pulls his knees toward his stomach. 5. The client coughs loudly.
Correct Answer: 1, 2, 3, 4 If the client's respiratory rate increases during the examination, it may indicate that the client is experiencing pain or anxiety. The client may move away from the nurse during the examination if the client is experiencing pain. Grimacing is a facial expression that can indicate that the client is experiencing pain during the assessment. The client who exhibits guarding behavior is most likely experiencing pain. The client who coughs loudly is not necessarily experiencing pain. This is not a typical expression of pain or anxiety.
The nurse is mapping the client's abdomen into four quadrants. Which landmarks would the nurse use to perform this assessment? Select all that apply. 1. Umbilicus. 2. Midclavicular lines. 3. Xiphoid process. 4. Lower border of the right ribs. 5. Iliac crests.
Correct Answer: 1, 3 To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal line perpendicular to the first line. The midclavicular lines, lower border of the right ribs, or iliac crests are not used to map the client's abdomen into four quadrants.
The nurse is preparing an educational presentation regarding the Healthy People 2020 objectives. Which topics are appropriate and related to the objectives? Select all that apply. 1. Educate pregnant women regarding the importance of small, more frequent dry meals throughout the day to reduce nausea and vomiting. 2. Educate Asian men about the importance of avoiding alcohol because this is a population that is prone to alcohol abuse. 3. Educate people who are anticipating traveling to India, Asia, Africa, or Central America about ways to reduce their risk of becoming infected with hepatitis E virus. 4. Educate immunocompromised populations and those caring for them about the importance of safe food handling. 5. Educate people about the relationship between regular, thorough oral hygiene practices and good nutrition.
Correct Answer: 1, 3, 4, 5 Pregnant women who eat smaller, dry meals throughout the day are less likely to experience nausea and vomiting than women who eat fewer, larger meals during the day. People who travel to India, Asia, Africa, or Central America are more likely to become infected with hepatitis E virus. Immunocompromised clients are more prone to developing foodborne illnesses. Safe food handling when preparing food for these clients is very important. Poor oral hygiene is associated with malnutrition. Caucasian and Hispanic populations are more prone to alcohol abuse than Asians.
An adolescent client is seen for abdominal pain in the local clinic. The client states, "The pain is sort of all over my belly. I can't really find one place that hurts more than another area." Based on the nurse's understanding about disorders of abdomen and associated symptomatology, which nursing diagnoses are appropriate for this client? Select all that apply. 1. Acute pain. 2. Hypothermia. 3. Diarrhea. 4. Altered urinary elimination. 5. Altered nutrition, less than body requirements.
Correct Answer: 1, 3, 5 This client is most likely experiencing clinical manifestations associated with ulcerative colitis. Ulcerative colitis is a recurrent inflammatory process causing ulcer formation in the lower portions of the large intestine and rectum. This condition is common in adolescents and young adults. The client is currently experiencing diffuse acute pain. The client will commonly complain of diarrhea, and may experience weight loss. It would be unusual for the client to complain of hypothermia or have a lowered body temperature. The client with ulcerative colitis will not typically experience altered urinary elimination.
A client asks the nurse, "What's the purpose of the liver?" Which statements will the nurse include in the response to this client's question? Select all that apply. 1. "It helps you digest fats." 2. "It is an endocrine and exocrine gland." 3. "It filters waste from the blood and makes urine." 4. "It makes some blood-clotting substances." 5. "It can help you store certain vitamins."
Correct Answer: 1, 4, 5 The liver produces and secretes bile for fat breakdown, but also aids in the metabolism of proteins and carbohydrates. It stores some vitamins, helps with blood coagulation, produces antibodies, and detoxifies some harmful substances. The pancreas is an example of an exocrine and endocrine gland. The kidneys filter nitrogen waste from the blood and make urine.
The nurse is preparing to examine a client who is complaining of right lower quadrant abdominal pain. Which actions by the nurse are appropriate in this situation? Select all that apply. 1. "It is a little cool in our examination room; may I turn up the thermostat?" 2. "I've been told you are experiencing some pain in the lower right area of your abdomen. I will examine that area first." 3. "I am going to stand on your left side so I can feel your liver better." 4. "I'm going to place this drape over you so you don't feel too exposed during this examination." 5. "I am going to place this pillow behind your head and this pillow under your knees."
Correct Answer: 1, 4, 5 The nurse should provide an environment that is warm and comfortable. Maintain the dignity of the client through appropriate draping techniques. The client should be in a supine position with a small pillow placed beneath the head and knees. When a client is experiencing abdominal pain, the nurse should examine that area last. Stand on the right side of the client, because the liver and the right kidney are in the right side of the abdomen.
The client's current body weight is 342 pounds. The nurse wants to calculate the client's body mass index (BMI). What is the client's current weight in kilograms? ______ kilograms
Correct Answer: 155.5 kilograms There are 2.2 pounds in 1 kilogram. The client's weight in kilograms is 155.5 kilograms.
The nurse is performing an abdominal assessment on an infant. The nurse notes that the umbilicus is bulging and has been displaced slightly to the left of midline. Based on this data, which diagnosis does the nurse anticipate? 1. Infection. 2. Umbilical hernia. 3. Ventral hernia. 4. Hiatal hernia.
Correct Answer: 2 An umbilical hernia occurs at the umbilicus and allows the intestines or other abdominal structures to protrude through the abdominus rectus muscle and come closer to the skin. This is not a normal finding in an infant. A protruding or displaced umbilicus is a normal variation in pregnant females. This is not a sign of infection. Ventral hernias occur in previous incisional sites. A hiatal hernia is due to a weakening in the diaphragm that allows a portion of the stomach and the esophagus to move into the thoracic cavity. This type of hernia is more commonly found in adults than in children.
The nurse is caring for a client diagnosed with the hepatitis A virus. The client requests information about how the virus is transmitted. Which statement by the nurse is appropriate? 1. "This virus is transmitted by sexual contact with someone who already has been infected with this virus." 2. "Most likely, you ate something that was contaminated with the virus." 3. "It is spread by blood transfusions." 4. "Have you ever injected an illegal drug?"
Correct Answer: 2 Educating clients about hepatitis A, B, and C viruses is included in the Healthy People 2020 objectives. Education about the viruses can help reduce transmission. Hepatitis A virus is transmitted through enteric routes and is usually the result of eating food that was contaminated with the virus. Hepatitis B virus is transmitted parenterally, sexually, or perinatally. Hepatitis C virus is transmitted via blood and blood products, parenterally, and through other unknown factors. Hepatitis B, C, and D viruses can be transmitted parentally and the client may be infected while injecting illegal drugs.
A client asks the nurse, "What's the purpose of a gall bladder anyway? My mom lived for many years without her gallbladder." Which information would be beneficial for the nurse to share with this client? 1. "You are right. We still don't know the function of the gallbladder." 2. "It stores bile until it is needed for digestion of fats." 3. "It destroys old red blood cells." 4. "It helps you digest carbohydrates by producing enzymes."
Correct Answer: 2 The gallbladder is used to store bile. It is a thin-walled sac that is nestled in a shallow depression on the ventral surface of the liver. The gallbladder releases stored bile into the duodenum when stimulated and thus promotes the emulsification of fats. The main functions of the gallbladder are storing of bile and assisting in the digestion of fats. The spleen destroys red blood cells. The pancreas helps the body digest carbohydrates.
The nurse is performing a focused interview with an older adult client. Which statements by the client are expected? Select all that apply. 1. "I have been having loose stools every day for the last 3 years." 2. "I know I just don't drink as much water as I should." 3. "My belly seems softer and flabbier as I get older." 4. "My mouth is always dry." 5. "My heartburn gets worse the older I get."
Correct Answer: 2, 3, 4 Older clients tend to experience constipation as a result of changes in their digestive tracts. Loose stools are an unexpected finding in the older client. Older clients do not tend to drink as much water as they should to avoid frequent urination. The older client's abdomen tends to be softer and more relaxed than in the younger adult. The older client's saliva production is decreased resulting in a dry mouth. The older adult produces less gastric acid, leading to improvement of heartburn. Increased heartburn would be an unexpected finding.
The nurse is completing discharge instructions for a client admitted with esophagitis. Which client statements indicate the need for further education? Select all that apply. 1. "I'm going to talk to my doctor about a nicotine patch." 2. "I can do all of this stuff you're talking about as long as I don't have to give up my beer." 3. "I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle." 4. "The root of this problem is that I just sleep too much." 5. "I told my wife to stop making serving me all of those vegetables."
Correct Answer: 2, 4, 5 Alcohol can exacerbate and is an established risk factor for the development of esophagitis. Sleeping "too much" is not associated with the development of esophagitis. Eating vegetables is not associated with the development of esophagitis. Smoking cigarettes is associated with an increased risk for developing esophagitis. Eating foods that are either too hot or too cold can be irritating to the tissue and can result in esophagitis.
The nurse is assessing a client in the emergency department (ED) who complains of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. Based on the client's assessment data, which conditions does the nurse suspect? Select all that apply. 1. Constipation. 2. Appendicitis. 3. Cholecystitis. 4. Small bowel obstruction. 5. Peritonitis.
Correct Answer: 2, 5 A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation or appendicitis. Constipation is not typically associated with a positive psoas sign. The client with cholecystitis may exhibit a positive Murphy's sign. The client with a small bowel obstruction may exhibit abnormal bowel sounds.
The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. As the nurse inspected the client's abdomen and notes ascites. Based on this data, which interventions will the nurse perform next? Select all that apply. 1. Obtain stool specimen for occult blood. 2. Measure the client's abdominal girth. 3. Obtain stool specimen for culture and sensitivity. 4. Bilateral leg measurements. 5. Percuss the abdomen at midline.
Correct Answer: 2, 5 The nurse should measure the client's abdominal girth to obtain baseline information for further comparisons. The nurse should percuss the abdomen at midline for tympany because this is a sign of ascites. The nurse would not necessarily suspect that the client had occult blood in the stool. The nurse does not need to send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed that the client had an infection within the gastrointestinal tract. The nurse does not necessarily need to measure the circumferences of the client's legs for edema.
The nurse is performing an abdominal assessment on a client. While the nurse is palpating the lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client complains of a sharp pain located in the right upper quadrant. How will the nurse document this finding in the medical record? 1. Positive Blumberg sign. 2. Presence of pain at McBurney point. 3. Positive Murphy sign. 4. Positive Psoas sign.
Correct Answer: 3 Pain with palpation of the liver is indicative of cholecystitis and is noted as a positive Murphy's sign. The examination should be halted. Blumberg sign is sharp pain occurring with the release of a compressed area and is present when the client has peritoneal irritation. Pain at McBurney point in the right lower quadrant is associated with appendicitis. Pain that is elicited while flexing the hip is indicative of psoas muscle irritation and is associated with peritoneal inflammation or appendicitis.
The nurse is assessing the client's abdomen and notes dullness when percussing over the left lower quadrant. Which question is most appropriate for the nurse to ask the client at this time? 1. "How much alcohol do you drink?" 2. "Do you have pain after eating?" 3. "When was your last bowel movement?" 4. "Have you ever had splenomegaly?"
Correct Answer: 3 Percussion over the abdomen produces tympany, and dullness is heard over the solid organs such as the liver and spleen. Dullness in the left lower quadrant may indicate the presence of stool in the colon. Dullness may also indicate an enlarged uterus, distended urinary bladder or ascites. Significant alcohol consumption may be associated with possible liver enlargement. The nurse would be able to percuss the liver in the right upper quadrant. Pain after eating is more likely to be associated with an upper gastrointestinal problem. Splenomegaly is associated with dullness while percussing the client's left upper quadrant.
The nurse is completing an abdominal assessment and is percussing over the left side of the upper portion of the client's abdomen over the area of the stomach. The client states, "I haven't had my breakfast, yet." Based on this statement, which does the nurse anticipate? 1. Dullness. 2. Flatness. 3. Tympany. 4. Hyperesonance.
Correct Answer: 3 Tympany is a loud, drum-like sound heard over structures filled with air, such as the stomach or air in the intestines. Dullness is a soft to moderate thud-like sound heard over solid organs such as the liver. If heard over the stomach, dullness suggests a stomach mass and also may be heard after a large meal. Flatness is a soft, flat sound heard over muscle or bone. Hyperresonance is a hollow sound that is louder than tympany and is heard over air-filled or distended intestines.
The nurse is documenting the findings of an abdominal assessment on a client and documents the following information, "pain noted during palpation at McBurney point." How did the nurse elicit this response during the assessment? 1. The nurse lightly palpated the around the client's umbilicus. 2. The nurse pressed into the client's abdomen and then pulled his hand back quickly. 3. The nurse palpated over the client's spleen. 4. The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.
Correct Answer: 4 McBurney point is located 2.5 to 5.1 centimeters above the anterosuperior iliac spine, on a line between the ileum and the umbilicus. When the client experiences pain at this site with palpation it is referred to as a positive Rovsing sign, which is suggestive of peritoneal irritation that is most frequently associated with appendicitis. Pain with palpation over the umbilicus may indicate an infectious process such as diverticulitis. A hernia may be palpated or visualized during the nurse's inspection of the client's abdomen. Pain as an area is compressed and then is allowed to decompress is known as a positive Blumberg sign. This sign occurs in clients with peritoneal irritation. Normally, the client should feel pressure but no pain as the nurse palpates the client's spleen.
The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the stethoscope. The nurse hears a soft, continuous humming sound. Based on this data, the nurse suspects dysfunction with which organ? 1. Stomach. 2. Spleen. 3. Pancreas. 4. Liver.
Correct Answer: 4 The nurse is hearing an abnormal abdominal sound called a venous hum, which is indicative of portal hypertension. Portal hypertension is the result of liver congestion. Dysfunction in the client's stomach, spleen, or pancreas most likely did not result in this type of sound.
The client was recently admitted to the hospital with left lower quadrant pain. The client states, "It feels like my belly is cramping." During the focused interview, the client admitted to experiencing a significant amount of occupational stress. Guarding is noted during the abdominal examination. The nurse reviews the medical record (see chart below) and concludes that the client has developed a diverticulitis. Which client statement supports this conclusion by the nurse? Assessment or diagnostic test: White blood cell count: 25,000/mm3 Red blood cell count: 4.2 x 1012/L Temperature: 101.2 degrees Fahrenheit Blood pressure: 152/84 1. "I get home so late at night, but I've got to stop lying down right after dinner." 2. "I drink a whole pot of coffee every day." 3. "I drink 9-12 beers after I get home from work, every day." 4. "We have been growing green beans in our garden and I think I ate too many the other day."
Correct Answer: 4 This client most likely is experiencing diverticulitis. The client's white blood cell count, temperature, and blood pressure are elevated as a result of the infection. High-fiber food intake can be a precipitating factor. Lying down after meals is often associated with gastroesophageal reflux disorder. Caffeine intake is associated with irritable bowel syndrome. Drinking alcohol is associated with irritable bowel syndrome and pancreatitis.
The nurse is palpating the left upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply. 1. Liver. 2. Gallbladder. 3. Appendix. 4. Spleen. 5. Stomach.
Correct Answer: 4, 5 The spleen and stomach are located in the left upper quadrant. The liver and gallbladder are located in the right upper quadrant. The appendix is located in the right lower quadrant.
The nurse is performing an abdominal assessment on the client. Rank the assessment steps in the order in which they should occur. Click on the down arrow for each response in the right column and select the correct choice from the list. 1. Percuss the abdomen. 2. Visualize the quadrants of the abdomen. 3. Palpate the abdomen. 4. Auscultate the abdomen. 5. Encourage the client to void.
Correct Answer: 5, 2, 4, 1, 3 The client should be encouraged to void prior to the abdominal assessment. Physical assessment of the abdomen requires the use of inspection, auscultation, percussion, and palpation. This order differs from that of physical assessment of other systems. The nurse should remember to auscultate after inspection. Delaying percussion and palpation prevents disturbance of the normal bowel sounds. During each of the procedures the nurse is gathering data related to problems with underlying abdominal organs and structures.