Chapter 23

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what? a) Abdominal aortic aneurysm b) Abdominal tumor c) Acites d) Inflammation

Abdominal aortic aneurysm Explanation:Pulsation of the aorta may be increased and lateralized in an abdominal aortic aneurysm. Ascites is collection of fluid in the abdomen. Inflammation and tumors do not pulsate

The nurse suspects an abdominal aortic aneurysm when what is assessed? Abdominal bruit Increased femoral pulses Hypertension Warm extremities

Abdominal bruit

Which of the following assessment findings would need to be reported the physician immediately? Absent bowel sounds, vomiting undigested food Constipation Chest fullness, heartburn and nausea after eating Diarrhea and flatus

Absent bowel sounds, vomiting undigested food

A 26-year-old sports store manager comes to the clinic with severe right-sided abdominal pain for 12 hours. He began having a stomach ache yesterday with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 38.8° and his heart rate is 170. His bowel sounds are decreased, and he has rebound and involuntary guarding at one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain? Acute appendicitis Acute mechanical intestinal obstruction Acute cholecystitis Mesenteric ischemia

Acute appendicitis

Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause? An enlarged liver felt during palpation Report of a decrease in appetite Tympany percussed over the stomach Negative fluid wave test

An enlarged liver felt during palpation

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? Peptic ulcer Cholecystitis Pancreatitis Appendicitis

Appendicitis

The nurse would assess for positive Blumberg sign how? Applying blunt pressure that the midclavicular line (MCL) Applying blunt pressure at the costovertebral angle (CVA) Applying and releasing pressure to the abdomen Having the client breathe deeply

Applying and releasing pressure to the abdomen Blumberg sign - If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen halfway between the umbilicus and the anterior iliac crest

A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend? Avoid taking pain medications with food Avoid taking antacid medications Avoid eating overcooked foods Avoid excessive alcohol intake

Avoid excessive alcohol intake Explanation:The nurse should recommend avoiding excessive alcohol intake, as this is a risk factor associated with peptic ulcer disease. The nurse should also recommend eating foods that have been cooked completely and taking pain medications with food. Antacid medications may relieve peptic ulcers

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? Hypoactive Erratic Absent Borborygmus

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.

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? Crohn's disease Gastric ulcer Pancreatitis Gastroesophageal reflux

Crohn's disease

When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize? Family history; dietary habits Dietary habits; social patterns Surgical history; family history Social patterns; past medical history

Family history; dietary habits

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? Escherichia coli Staphylococcus aureus Streptococcus pyogenes Helicobacter pylori

Helicobacter pylori

A nurse is working with an older client who has had diarrhea for the past week and is dehydrated. The nurse understands that older clients are especially at risk for potential complications with diarrhea due to which of the following factors? Tendency to have an inadequate fluid intake Large numbers of medications taken Higher fat-to-lean muscle ratio Decreased sensitivity to pain

Higher fat-to-lean muscle ratio

What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen? Epigastric Hypogastric Hypochondriac Inogastric TAKE ANOTHER QUIZ

Hypogastric

The nurse as elicited a positive Murphy sign. The knows this is indicates what? Kidney pain Peritonitis Appendicitis Inflammation of the gallbladder

Inflammation of the gallbladder Murphy's sign - Pain elicited when pressure is applied under the liver border at the right costal margin and client inhales deeply.

A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following? Peritoneum Linea alba Internal abdominal oblique Transverse abdominis

Linea alba

A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse? Document the absence of bowel sounds Assess for findings of dehydration Listen for a total of 5 minutes Palpate for abdominal rigidity

Listen for a total of 5 minutes

Where is the linea alba located? Middle of the ventral abdominal wall Lower edge of the costal margin Anterior-superior iliac spine of the iliac bones Xiphoid process of the sternum

Middle of the ventral abdominal wall

How should the nurse perform blunt percussion over the liver? Place left hand on right lower rib cage, strike it with ulnar side of right fist Place right hand on mid of the rib cage; strike it with ulnar side of left fist Place left hand on right lower rib cage, strike it with radial side of right fist Place right hand on mid of the rib cage; strike it with ulnar side of left fist

Place left hand on right lower rib cage, strike it with ulnar side of right fist

The client would complain of pain in what quadrant if experiencing appendicitis? RUQ RLQ LUQ LLQ

RLQ

The nurse plans to assess a client's liver border. Which area of the abdomen is the nurse going to assess?

RUQ

Which of the following statements provides the most accurate guide to the assessment of the gallbladder? The gallbladder should be percussed and palpated prior to the liver to avoid confusing it with the larger organ. The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Cholecystitis and cholelithiasis are not amenable to diagnosis in the clinical setting. The margins of the gallbladder are obscured by the spleen.

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.

A nurse suspects that a client has gastroesophygeal reflux disease (GERD). Which risk factors must be present for the nurse to confirm this? Select all that apply. body mass index greater than 30 taking multiple medications hiatal hernia alcohol consumption passing excess flatus

body mass index greater than 30 taking multiple medications hiatal hernia

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 liver disease. abdominal distention. Cushing syndrome. internal bleeding.

internal bleeding.

The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible aortic aneurysm. paralytic ileus. gastroenteritis. fluid and electrolyte imbalances.

paralytic ileus.

A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment? place a small pillow under the client's knees raise the head of the bed to a 30-degree angle remove a pillow from behind the client's head assist to a sitting position with the legs dangling

place a small pillow under the client's knees

During an assessment, the patient describes vomiting moderate amounts that "smell like poop." The nurse might suspect small bowel obstruction gastric varices hypercalcemia irritable bowel syndrome

small bowel obstruction

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 umbilical hernia. ascites. intra-abdominal bleeding. pancreatitis.

umbilical hernia.

A nurse is assessing a client with a history of alcohol abuse. The client reports right upper quadrant pain. Which type of pain is the client experiencing? visceral parietal referred musculoskeletal

visceral 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

A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining whether this client is truly experiencing an alteration in bowel pattern? "What is the consistency of your stools?" "How many times a day are you having a bowel movement?" "Do you have a bowel movement every day?" "Have you changed your food intake this week?"

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