HA Chapter 23: Abdomen PrepU (COMBINED)
A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining if this client is truly experiencing an alteration in bowel pattern? "Have you changed your food intake this week?" "How many times a day are you having a bowel movement?" "What is the consistency of your stools??" "Do you have a bowel movement every day?"
"How many times a day are you having a bowel movement?"
A nurse observes 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? "Do you have high blood pressure?" "How many times have you been pregnant?" "Are you experiencing any abdominal pain?' "Have you noticed any color change to the skin?'
"How many times have you been pregnant?"
Describe the size of the kidney, location according to vertebrate and which kidney is lower?
10x5x2.5 T12-L3 The right kidney sits lower
when ausculating the abdomen listen to all _ quadrants and proceed in a _________ fashion
4, clockwise
how many abdominal clicks per minute are normal
5-30
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 lowe
A
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 smal
A
The nurse assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C (99.3°F;). Which of the following interventions is appropriate for this client? A) monitor pulse and blood pressure every 15 minutes until stable B) get a physical therapy consult C) assess for signs of hypervolemia D) monitor intake and output and weights once a week
A
The nurse understands this abdominal organ is responsible for storing red blood cells and platelets. A) spleen B) liver C) pancreas D) gall bladder
A
The nurse would assess for positive Blumberg sign how? A) applying and releasing pressure to the abdomen B) applying blunt pressure to the midclavicular line C) having the client breathe deeply D) applying blunt pressure at the costovertebral angle
A
Some changes that appear on the skin of the abdomen as a result of pregnancy are what? Select all that apply. A) striae B) everted umbilicus C) linea nigra D) hemorrhoids E) inverted umbilicus
A, B, C
The nurse would assess for positive Blumberg sign how? Applying blunt pressure at the costovertebral angle (CVA) Having the client breathe deeply Applying and releasing pressure to the abdomen Applying blunt pressure that the midclavicular line (MCL)
Applying and releasing pressure to the abdomen
What do you do ask the patient to do before you perform an abdominal assessment?
Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination. (Weber 484)
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 interprets this as which of the following? (pg 627) A) psoas sign B) positive Rovsing's sign C) obturator sign D) positive skin hypersensitivity test
B
To promote relaxation of the 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) place a pillow under both of the clients knees C) cover the client in a warm blanket D) assure the client that painful areas will not be examined
B
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? A) left upper B) right upper C) right lower D) left lower
B
A 23-year-old man has recently graduated from university and is preparing to embark on a backpacking trip around Southeast Asia. In preparation for his trip, the client has visited a clinic to obtain vaccinations. The client will be able to obtain vaccines protecting against which of the following? A) hepatitis A B) hepatitis C C) hepatitis A and B
C
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) appendicitis D) pancreatitis
C
The nurse assess for kidney tenderness at what location? A) midclavicular line B) hypogastric area C) costovertebral angle D) umbilical region
C
The nurse auscultates 20 clicks and gurgles over 1 minute when examining a patients abdomen. How should the nurse document this finding? A) bowel sounds hyperactive B) bowel sounds inconsistent C) bowel sounds normal D) bowel sounds hypoactive
C
Which of the following acute abdominal symptoms could be life threatening? A) striae B) indigestion C) abdominal pain D) kidney stones
C
A client reports a decrease in appetite over the past month. What additional assessment should a nurse gather in relation to this data? Select all that apply. A) urine output B) height C) weight D) food intake E) activity level
C, D
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
What if you spot dark bluish-pink striae?
Cushing's syndrome
A 22-year-old law student comes to the office complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs, but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank around 14 drinks. Examination shows a young man appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigas
D
A nurse auscultates for bowels sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after one minute. What is an appropriate action by the nurse? A) document the absence of bowel sounds B) assess for findings of dehydration C) palpate for abdominal rigidity D) listen for a total of five minutes
D
During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate? A) assess urinary output B) refer the client for medical follow-up C) evaluate further for a problem with the spleen D) document the position of the liver
D
The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? A) liver engorgement B) kidney pain C) inflammation of the gallbladder D) appendicitis
D
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? Decreased sensitivity to pain Large numbers of medications taken Tendency to have an inadequate fluid intake Higher fat-to-lean muscle ratio
Higher fat-to-lean muscle ratio Older adult clients are especially at risk for potential complications with diarrhea, such as fluid volume deficit, dehydration, electrolyte, and acid-base imbalances, because they have a higher fat-to-lean muscle ratio. because they are fat!
What is pyrosis?
Indigestion
what is peritonitis?
Inflammation of the membrane lining the abdominal wall and covering the abdominal organs.
A client presents to the emergency department with reports of new onset of abdominal pain for the past three (3) days. The client states there is also a pulling feeling on the right side. Upon examination the nurse notices a 5cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process? Intestinal obstruction at the sigmoid colon Internal adhesions from previous surgery Peritonitis from a ruptured diverticulum Acute onset of appendicitis with possible rupture
Internal adhesions from previous surgery
What section is the sigmoid colon in?
LLQ
what section is the left ovary and left fallopian tube in?
LLQ
what section is the left ureter in?
LLQ
What section is the pancreas in?
LUQ
What section is the spleen in?
LUQ
What section is the stomach in?
LUQ
what section is the left adrenal gland in?
LUQ
Your patient 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 patient? Malabsorption syndrome Crohn disease Lactose intolerance Ulcerative colitis
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. like diarrhea
Why are old people more prone to UTI's
Older adult clients are prone to UTIs because the activity of protective bacteria in the urinary tract declines with age. (Weber 479)
How should the nurse perform blunt percussion over the liver? 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 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
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? Inform the client that the pen mark on the abdomen should not be washed off Ask the client to be seated and relaxed when taking the measurement Ensure that the client has had a full meal before measuring the abdomen Place the tape measure behind the client and measure at the umbilicus
Place the tape measure behind the client and measure at the umbilicus
What section is the ascending colon in?
RLQ
What section is the cecum, and appendix in?
RLQ
What section is the liver in?
RUQ
what quadrant is the gallbladder in?
RUQ
what quadrant is the head of the pancreas in?
RUQ
what quadrant is the liver in?
RUQ
When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach. T/F
T
How many layers of muscle are in your abdominal area?
The abdominal contents are enclosed externally by the abdominal wall musculature, which includes three layers of muscle extending from the back, around the flanks, to the front. (Weber 473)
What is psoas test?
The one where they kick up and you hold it down or they kick back while on their side.
What are the three layers and what order.
The outermost layer is the external abdominal oblique, the middle layer is the internal abdominal oblique, and the innermost layer is the transverse abdominis (Weber 473) (transfers is deepest)
spleen function?
The spleen functions primarily to filter the blood of cellular debris, to digest microorganisms, and to return the breakdown products to the liver. (Weber 475)
true or false, liver size decreases after age 50?
True
What is Murphy's sign?
When you curl a finger under the rib cage right by the liver and then ask the patient to take a deep breath. If there is pain then that is a gallbladder or liver problem.
When you are observing the aortic pulsations and they are exaggerated, what is this potentially a sign of?
abdominal aortic aneurysm
out pouching of arterial wall resulting from a weakened or damaged medial arterial layer
abdominal aortic aneurysm
A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen? Absent Hyperactive Erratic Hypoactive
absent
The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? Kidney pain Inflammation of the gallbladder Appendicitis Liver engorgement
appendicitis
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? Borborygmus Absent Erratic Hypoactive
borborygmus
To assess for a CVA you percuss at the ______ angle
costovertebral
The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the left upper quadrant. costovertebral angle. external oblique angle. right upper quadrant.
costovertebral angle. The angle found on your back made by the bottom ribs meeting at an angle
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should palpate lightly while slowly releasing pressure. palpate deeply while quickly releasing pressure. ask the client to assume a side-lying position. perform this abdominal assessment first.
deep and quick
The pancreas of an adult client is located posterior to the left midaxillary line and posterior to the stomach. below the diaphragm and extending below the right costal margin. high and deep under the diaphragm and can be palpated. deep in the upper abdomen and is not normally palpable.
deep in the upper abdomen and is not normally palpable.
The nurse is performing an assessment on a client that is on postop day 2. The abdominal wound has pulled apart and the contents are spilling out. The nurse recognizes this as a what? Hernia Dehiscence Infection Abscess
dehiscence
During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should begin auscultation in the left upper quadrant. listen in each quadrant for 15 seconds. palpate the abdomen before auscultation. use the diaphragm of the stethoscope.
diaphragm
amino acids can be metabolized into what three things?
energy, glucose or fat
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? Bleeding Inflammation Obstruction Fluid accumulation
fluid accumulation
Which of the following people need to be vaccinated for hepatitis A and B? Truck drivers Animal care workers Food-service workers Office personnel
food service
grating sounds that increase with inspiration. They may indicate a liver tumor, splenic infarction, or peritoneal inflammation
friction rub
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? Helicobacter pylori Escherichia coli Staphylococcus aureus Streptococcus pyogenes
h pylori
soft pitched humming noise and indicate partial obstruction of an artery and reduced blood flow to the organ
hums
The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation? identify abdominal organs detect abdominal tenderness discern muscular resistance complete a surface evaluation
identify abdominal organs deep palpation is to identify the organs , light is to identify tenderness
What are the functions of the liver?
including glucose storage, formation of blood plasma proteins and clotting factors, urea synthesis, cholesterol production, bile formation, destruction of red blood cells, storage of iron and vitamins, and detoxification. (Weber 474)
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. internal bleeding. abdominal distention. Cushing syndrome.
internal bleeding
Where in the digestive tract is most of the water absorbed? Stomach Duodenum Large intestine Ileum
large intestines
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the left upper quadrant. right lower quadrant. right upper quadrant. left lower quadrant.
left upper quadrant
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? Transverse abdominis Internal abdominal oblique Peritoneum Linea alba
linea alba
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 gallbladder disease. cachexia. kidney trauma. masses.
masses
A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement? Palpate the abdomen Perform percussion for tympany Measure abdominal girth Auscultate for bowel sounds
measure abdominal girth
You are assessing a patient for acute cholecystitis. What sign would you assess for? Psoas sign Cutaneous hyperesthesia Obstipation sign Murphy sign
murphy sign
During the abdominal examination a nurse supports the client's right knee and ankle. The nurse flexes the client's hip and rotates the leg externally and internally. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign? Rovsing's Murphy's Obturator Psoas
obturator
Describe parietal pain?
occurs when the parietal peritoneum becomes inflamed, as in appendicitis and peritonitis
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 fluid and electrolyte imbalances. aortic aneurysm. paralytic ileus. gastroenteritis.
paralytic ileus
Describe referred pain?
ravels, or refers, from the primary site and becomes highly localized at the distant site (Weber 481)
what is a blumberg sign?
rebound tenderness
To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's left upper quadrant. right upper quadrant. right lower quadrant. left lower quadrant.
right lower quadrant.
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? right lower left lower left upper right upper
right upper
percussion is used to determine organ _____ and ______
size, tenderness
Most absorption of nutrients occurs where in the GI?
small intestines
What equipment do you need for an abdominal assessment?
small pillow -centimeter ruler -stethoscope -marking pen
what are two risk factors for abdominal aortic aneurysm
smoking and hypertension
What is the difference between solid viscera and hollow viscera?
solid retain their shape always like a liver, while hollow adjust to the contents inside like the stomach.
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? Spleen Gallbladder Liver Pancreas
spleen
What is borborygmus?
stomach growling
Abdominal organs are supplied with blood from what vessels?
the abdominal aorta and its major branches, which are the left and right iliac arteries
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites? Dullness that remains despite change in position Dullness centrally when the client is supine Tympany that changes location with client position Bilateral flank tympany
tympani that changes location with the client position
The nurse assesses a client's indwelling urinary catheter bag and observes cloudy urine. The client also complains of lower back pain. What is the nurse's best action? Flush the catheter tubing with sterile normal saline. Record the findings as expected for a client with an indwelling catheter. Prepare to obtain a urine specimen for culture. Encourage the client to increase PO fluid intake.
urine specimen for culture
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? alcohol hepatitis viral hepatitis intrahepatic jaundice toxic liver damage
viral hepatitis
