N366 Final Abdomen, Peripheral Vascular

Listen with the bell of the stethoscope for vascular sounds

A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10-year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time?

Gallbladder

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved?

The left lower quadrant is palpated last

A client reports severe pain in the left lower quadrant of three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history?

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

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?

Murphy's

A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?

At the symphysis pubis

A client's bladder is found to be distended. At which location would the nurse begin palpating?

Inspect, auscultate, percuss, palpate

A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Spleen

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant?

Document this finding as normal

A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following would the nurse do next?

Document the finding as normal

A nurse assesses capillary refill time in a client and finds it to be less than 2 seconds. What is an appropriate action by the nurse?

Listen for a total of five (5) minutes

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?

Assist the client to walk as soon and as often as possible

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

It is a normal-sized liver

A nurse determines that the liver span of an older adult male client measures 6 cm. How would the nurse would interpret this finding?

Absent

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?

Visible peristaltic waves

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem?

Kidney

A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ?

Size, symmetry, and skin colour

A student in the vascular surgery clinic is asked to perform a physical examination on a client with known peripheral vascular disease in the legs. Which of the following aspects are most important to note?

Tympany

A student is performing a physical assessment on a client. While assessing the abdomen, the student percusses the spleen. What sound would be normal for the student to hear?

Appendicitis

An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What might this client's medical diagnosis be?

Student compresses the client's nailbed until it blanches

An instructor is observing a student assess a client's capillary refill. Which action by the student indicates the proper technique?

Cholecystitis

Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect?

*Compare measurements of both extremities*

Assessment of a client's lower extremities reveals unilateral edema of the right extremity. Which of the following would be most appropriate for the nurse to do next?

4+

Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following?

Document the position of the liver

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?`

enlarged bladder

Mr. Kruger, 84 years old, presents with a smooth lower abdominal mass in the midline, which is minimally tender. There is dullness to percussion up to 6 cm above the symphysis pubis. What does this most likely represent?

Determine liver span by percussion

Mr. Patel, 64 years old, was told by another care provider that his liver was enlarged. Although he is a lifelong smoker with a history of emphysema, the client has never used drugs or alcohol, nor does he have any knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 cm below the costal arch. Which of the following would the examiner do next?

absent pulse is recorded as 0 pulse that is thready is recorded as 1+ one that is weak is recorded as 2+ normal pulse is recorded as 3+ 4+ bounding and does not disappear with moderate pressur

Pulse strength

brisk, expected (normal) pulse

The nurse documents a 2+ radial pulse. What assessment data indicated this result?

To check for possible dehydration

The nurse is admitting a new client to the floor and asks if the client has any dizziness. Why does the nurse do this?

Cirrhosis and nephrosis

The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by

Observe the client's face for signs of discomfort

The nurse is assessing an adult client with right lower quadrant abdominal pain. The client has no history of prior surgeries, has no allergies, and is physically fit. Which of the following should the nurse do during the abdominal examination?

Right lower quadrant

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location?

Femoral

The nurse is palpating the pulse just under the inguinal ligament. The nurse is assessing which pulse?

Take a deep breath in and hold it

The nurse is percussing a client's liver and is assessing liver descent. The nurse would have the client do which of the following?

Immobility

The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?

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

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?

Behind the ankle

The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate?

Use Doppler ultrasonography to locate the pulse

The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?

Venous insufficiency

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

Posterior tibial

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

bowel sounds normal

When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding?

right upper

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant?

Inspection

When performing the abdominal assessment for a client, which assessment technique should the nurse perform first?

Right kidney, ascending colon, and liver

When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant?

An enlarged liver felt during palpation

Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause?

Flex the client's legs by placing a pillow under the knees

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?

Abdominal pain

Which of the following acute abdominal symptoms could be life threatening?

Stop palpating and get medical assistance

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus?

Brachial

Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward?

To identify bowel sounds

While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen?