Abdominal Assessment
The nurse suspects an abdominal aortic aneurysm when what is assessed? Increased femoral pulses Hypertension Abdominal bruit Warm extremities
Abdominal bruit Explanation: Auscultation of the abdomen would reveal a bruit. The client may exhibit decreased femoral pulses, hypotension and cool extremities.
Which of the following acute abdominal symptoms could be life threatening? Abdominal pain Striae Kidney stones Indigestion
Abdominal pain Explanation: Severe dehydration from nausea and vomiting, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Striae, or stretch marks, usually accompany pregnancy or changes in weight and are not of themselves life threatening. Kidney stones are a disorder, not a symptom. Acute indigestion is usually not life threatening.
A nurse examines a client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of the client's abdomen? Hyperactive Borborygmus Absent Erratic
Absent
A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following? Normoactive Hyperactive Hypoactive Absent
Absent Explanation: Absent bowel sound may be associated with peritonitis, which would occur with a ruptured appendix. The bowel sounds would not be normal. Hypoactive bowel sounds indicate diminished bowel motility, such as from surgery or late bowel obstruction. Hyperactive bowel sounds indicate increased bowel motility, such as with diarrhea, gastroenteritis, or early bowel obstruction
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 epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending. What etiology of abdominal pain is most likely causing his symptoms? Acute pancreatitis Biliary colic Peptic ulcer disease Acute cholecystitis
Acute pancreatitis Explanation: Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates into the back. There is often a history of long-standing gallbladder disease or recent alcohol ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump inhibitors can also cause pancreatitis in people without these other risk factors. Treatment includes hydration, pain management, and bowel rest.
The nurse notes that a client experiencing right lower quadrant abdominal pain when the hip and knee are flexed, and the leg is rotated internally and externally. What should the nurse suspect is occurring with this client? Appendicitis Liver inflammation Inflamed gall bladder Peritoneal irritation
Appendicitis Explanation: The client is demonstrating a positive obturator sign that causes pain in the right lower abdominal quadrant when the hip and knees are flexed and the leg is rotated internally and externally.
A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem? Symmetric appearance No bulging with head raising Abdominal respiratory movements Visible peristaltic waves
Visible peristaltic waves Explanation: Visible peristaltic waves typically are not visible except in very thin people. An increase in peristaltic waves with progression in a ripple like fashion suggests intestinal obstruction, necessitating further evaluation.
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? "I'm going to examine the area where you're having pain first to get a better picture of what's going on." "Before I get ready to examine the painful area, I will let you know in plenty of time." "Since you're having pain in a certain area, I won't have to do a very thorough exam there." "You don't need to worry about anything. I will make sure to be very gentle during the exam."
"Before I get ready to examine the painful area, I will let you know in plenty of time." Explanation: The nurse would determine which area or areas are causing the client discomfort or pain and assess those areas last. In addition, the nurse would reassure the client that he or she will forewarn the client when the areas will be examined. The nurse need to approach the client with slow, gentle, and fluid movements. Telling the client not to worry is inappropriate even if the nurse will be gentle during the examination. The area of pain requires just as thorough an exam as other areas and possibly a more in-depth examination if necessary.
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? "Are you currently taking vitamin supplements?" "Do you take painkillers like aspirin on a regular basis?" "Do you tend to eat foods that are quite high in fat?" "Do you feel like you're able to adequately address the stress in your life?"
"Do you take painkillers like aspirin on a regular basis?" Explanation: Regular use of nonsteroidal anti-inflammatory medications (NSAIDs) is implicated in the incidence of PUD.
A nurse observes silvery, white 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 regard to this finding? "Have you noticed any color change to the skin?" "Have you been pregnant?" "Do you have high blood pressure?" "Are you experiencing any abdominal pain?"
"Have you been pregnant?" Explanation: Striae are silvery white marks that are common on the abdomen from stretching of the skin during pregnancy or weight gain.
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 Pancreatitis Cholecystitis Appendicitis
Appendicitis Explanation: This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.
The nurse would assess for positive Blumberg sign how? Having the client breathe deeply Applying blunt pressure at the costovertebral angle (CVA) Applying blunt pressure that the midclavicular line (MCL) Applying and releasing pressure to the abdomen
Applying and releasing pressure to the abdomen Explanation: Pain that occurs after applying and releasing pressure to the abdomen would be a positive Blumberg sign. Murphy sign occurs when the client holds his breath and there is pain. Blunt pressure at the CVA assesses for kidney pain. Liver span test occurs at the MCL.
The nurse is assessing a client in the emergency department. The client was involved in a motor vehicle accident and is experiencing left upper abdominal pain. The nurse should intervene when another health care provider does which of the following? Attempts to palpate the spleen Places a cervical collar on the client Uses the left arm for phlebotomy Orders a spiral computerized tomography (CT) scan
Attempts to palpate the spleen Explanation: If trauma to the spleen is suspected, the spleen should not be palpated. Palpation could cause the spleen to rupture and the nurse should intervene to prevent this from happening. The nurse would expect for the client to be placed in a cervical collar as the client was in a motor vehicle accident. The cervical collar should remain in place until the neck and spine are deemed stable. A spiral computerized tomography (CT) scan is expected to be ordered to rapidly help identify injuries sustained during the accident. The nurse should also expected blood to be drawn quickly from any site available to monitor the hemoglobin and hematocrit, as there is a need to check for internal bleeding.
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? Bowel sounds normal. Bowel sounds inconsistent. Bowel sounds hypoactive. Bowel sounds hyperactive.
Bowel sounds normal. Explanation: Normal bowel sounds consist of clicks and gurgles that occur at an estimated frequency of 5 to 34 per minute. The nurse should document that the bowel sounds are normal. Twenty bowel sounds in a minute is not hyperactive, hypoactive, or inconsistent.
Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect? Ascites Splenomegaly Appendicitis Cholecystitis
Cholecystitis Explanation: A positive Murphy's signs is associated with acute cholecystitis
A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client? Ineffective Nutrition: Less Than Body Requirements Ineffective Health Maintenance Constipation related to decrease in fluid intake Risk for Fluid Volume Deficit
Constipation related to decrease in fluid intake Explanation: The nurse can confirm constipation because the major defining characteristics of decreased frequency and abdominal discomfort are present. A few days of altered nutrition does not meet the necessary criteria to confirm Ineffective Nutrition or Risk for Fluid Volume Deficit. Ineffective Health Maintenance cannot be confirmed because there is no evidence that the client lacks the knowledge to eat properly.
The nurse assess for kidney tenderness at what location? Midclavicular line Umbilical region Hypogastric area Costovertebral angle
Costovertebral angle Explanation: Blunt percussion at the costovertebral angle assesses for kidney tenderness. The liver is assessed at the midclavicular line. The hypogastric and umbilical regions are incorrect areas to assess for kidney pain.
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? Gastric ulcer Pancreatitis Gastroesophageal reflux Crohn's disease
Crohn's disease Explanation: Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize? Dietary habits; social patterns Family history; dietary habits Social patterns; past medical history Surgical history; family history
Family history; dietary habits Explanation: Poor diet and a family history are both identified as risk factors for colorectal cancer. These aspects of the history would supersede the client's surgical history and social patterns.
Why is the appearance of urine important to evaluate during an abdominal examination? Cloudy urine rules out urinary tract infection Blood could indicate cholecystitis Dark urine may be from dehydration Sediment in the urine could indicate malnutrition
Dark urine may be from dehydration
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 nursing action would be most appropriate? Assess urinary output. Document the position of the liver. Evaluate further for a problem with the spleen. Refer the client for medical follow-up.
Document the position of the liver. Explanation: The liver is located below the diaphragm in the right upper quadrant of the abdomen, extending just below the right costal margin, where it may be palpated. The findings are considered normal, and the client would not need a referral for medical follow-up. The exam detects the liver, not the spleen, which would be on the left side. There are no data to support the need for assessing the client's urinary output.
Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen? Provide privacy to the client and instruct him to relax Flex the client's legs by placing a pillow under the knees Raise the client's arms or fold them behind the head Avoid the use of pillow under the head during examination
Flex the client's legs by placing a pillow under the knees Explanation: The nurse should flex the client's legs by placing a pillow under the knees. This helps the abdominal muscles to relax and facilitates proper assessment.
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? Obstruction Inflammation Bleeding Fluid accumulation
Fluid accumulation Explanation: Pale and taut skin indicates significant abdominal swelling caused by accumulation of fluid in the abdominal cavity, or ascites. Bleeding within the abdominal wall would manifest as purple discoloration at the flanks. Inflammation of the peritoneum and obstruction of the intestine does not contribute to pale and taut abdominal skin.
Which of the following people need to be vaccinated for hepatitis A and B? Animal care workers Office personnel Food-service workers Truck drivers
Food-service workers Explanation: Hepatitis A and B immunizations are recommended for all infants; people whose work may expose them to blood, body fluids, or unsanitary conditions (i.e., health care, food services, sex workers); and those traveling to parts of the world where these illnesses are prevalent.
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? Hepatitis A and B Hepatitis C Hepatitis A Hepatitis B and C
Hepatitis A and B Explanation: Vaccines are available for hepatitis A and B.
A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process? Internal adhesions from previous surgery Peritonitis from a ruptured diverticulum Intestinal obstruction at the sigmoid colon Acute onset of appendicitis with possible rupture
Internal adhesions from previous surgery Explanation: The key to this question is the presence of the scar. The scar in the right lower quadrant should alert the nurse to the possibility of internal adhesions, which account for the pulling feeling the client reports
Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely? Cholecystitis Colon cancer Irritable bowel syndrome Inflammatory bowel disease
Irritable bowel syndrome Explanation: Although colon cancer should be a consideration, these symptoms are intermittent and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely, especially given that she is a young woman. This very common condition can be triggered by certain foods and stress.
A nurse determines that the liver span of an older adult male client measures 6 cm at the MCL. How would the nurse would interpret this finding? The liver is larger than normal. It is a normal-sized liver. The liver is smaller than normal. The liver has atrophied.
It is a normal-sized liver. Explanation: The normal liver span is 6 to 12 cm at the MCL and 4 to 8 cm at the MSL, so this is a normal finding. Liver size begins to decrease after age 50. If the measurement was greater than 12 cm, the client's liver would be enlarged. A decreased span suggests liver atrophy.
The nurse performs the technique shown when assessing a client. For what is this nurse assessing? Nerve root compression Pain referred from the lungs Kidney tenderness Location of the spleen
Kidney tenderness Explanation: Blunt percussion over the costovertebral angle is used to assess for kidney tenderness. This assessment technique is not used to assess for the spleen, nerve root compression, or referred lung pain.
Where in the digestive tract is most of the water absorbed? Stomach Ileum Large intestine Duodenum
Large intestine
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? Palpate for abdominal rigidity Assess for findings of dehydration Listen for a total of 5 minutes Document the absence of bowel sounds
Listen for a total of 5 minutes Explanation: Bowel sounds normally occur every 5 to 15 seconds. In a client with nausea and vomiting, bowel sounds may be hypoactive. The nurse should listen for a total of 5 minutes to confirm the absence of bowel sounds.
A nurse performs percussion by placing the left hand flat against the client's lower rib cage and striking it with the ulnar side of the right fist. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ? Kidney Gall bladder Spleen Liver
Liver Explanation: Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage and striking it with the ulnar side of the right fist.
The nurse is palpating in the right upper abdominal quadrant and feels and enlarged area. The nurse recognizes that she is most likely feeling what organ? Pancreas Kidneys Gallbladder Liver
Liver Explanation: The liver is located in the right upper quadrant. The gallbladder and kidney are not palpable. The pancreas is located in the left upper quadrant.
A client's most recent laboratory results indicate increases in alanine aminotransferase (ALT) and aspartate aminotransferase (AST). What might the nurse suspect is wrong with this client? GI bleed Gastroenteritis Liver disease Dehydration
Liver disease Explanation: Liver function tests (including alanine aminotransferase [ALT] and aspartate aminotransferase [AST] levels) indicate the health of the liver. Levels of these enzymes, which are necessary for digestion and absorption of nutrients, remain normal until liver compromise is significant.
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? Monitor intake and output and weights once a week Assess for signs of hypervolemia Get a physical therapy consult Monitor pulse and blood pressure every 15 minutes until stable
Monitor pulse and blood pressure every 15 minutes until stable
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? Observe the client's face for signs of discomfort Place the client supine with arms extended up Examine the abdomen with the client's bladder full Do not distract the client with questions while performing the examination
Observe the client's face for signs of discomfort
Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure? Overflow incontinence Functional incontinence Urge incontinence Stress incontinence
Overflow incontinence
The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant with right flank pain. Which assessment should the nurse conduct next? Palpate the right lower quadrant for rebound tenderness. Test for a fluid wave. Assess for the obturator sign. Assess for Murphy's sign.
Palpate the right lower quadrant for rebound tenderness. Explanation: Localized tenderness anywhere in the right lower quadrant, even in the right flank, suggests appendicitis. The nurse should follow this finding with an assessment of rebound tenderness. This will assist the nurse in determining if the client is guarding and develops muscle rigidity-two additional features of appendicitis. The test for fluid wave is used to identify ascites in the client. The manner in which the client presented does not warrant an assessment for ascites. Murphy's sign is used to assess for acute cholecystitis. A positive obturator sign can suggest inflammation of the appendix; however, this test has low sensitivity. For this reason, rebound tenderness should be assessed first.
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. How would the nurse document this finding? Positive skin hypersensitivity test Obturator sign positive Psoas sign present Positive Rovsing's sign
Positive Rovsing's sign Explanation: Findings indicating referred rebound tenderness constitute a positive Rovsing's sign. Psoas sign occurs when pain in the right lower quadrant occurs with raising of the client's right leg from the hip and pressure applied downward against the lower thigh. The obturator sign occurs when pain in the right lower quadrant results when the client's right knee and ankle are supported and the leg is rotated internally and externally. A positive hypersensitivity test occurs when the client experiences pain or exaggerated sensation when the abdomen is stroked with a sharp object.
The client would complain of pain in what quadrant if experiencing appendicitis? RUQ RLQ LUQ LLQ
RLQ
The nurse correctly identifies the gallbladder is located where? RUQ RLQ LUQ LLQ
RUQ
A client complains of a sudden onset of pain in the back. On questioning the client further, the nurse learns that the cause of the pain is acute pancreatitis. The nurse recognizes that this type of pain is which of the following? Referred pain Chronic pain Localized pain Radiated pain
Referred pain Explanation: Pancreatic inflammation, or pancreatitis, may be felt in the back. This is called "referred" pain because the pain is not felt at its source. This is not radiated pain, which extends continuously to the tissues surrounding the source, nor is it localized pain, which remains only in one small area. It is not chronic pain, as it results from acute pancreatitis.
The nurse is evaluating a new graduate's ability to perform a rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location? Right upper quadrant Left upper quadrant Left lower quadrant Right lower quadrant
Right lower quadrant Explanation: The appendix is located in the right lower quadrant. If the client has appendicitis, pressing deeply in this location with a sudden release of pressure will elicit a sharp, stabbing pain, which is called "rebound tenderness."
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? Pancreas Spleen Liver Gallbladder
Spleen
What would a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration? Intestinal air Splenomegaly Abdominal mass Hepatomegaly
Splenomegaly Explanation: Normally, tympany or resonance is heard at the last left interspace. Dullness suggest splenomegaly.
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? Provide a dietician consult for the client. Counsel the client regarding hernia repair. Refer the client to an oncologist. Stop palpating and get medical assistance.
Stop palpating and get medical assistance. Explanation: If the nurse palpates a prominent pulsating mass, the suspicion is high for an abdominal aortic aneurysm. The nurse should stop palpating immediately and seek medical assistance, because the risk of rupture is great.
When inspecting the abdomen, which of the following client positions facilitates correct examination technique? Supine with arms at sides or folded across chest Semi-Fowler's with pillows under head and knees Trendelenburg with hands over head Sitting with hands on hips
Supine with arms at sides or folded across chest
The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be? Perineal Suprapubic Back Upper abdomen
Suprapubic
The nurse is assessing an adult client with severe abdominal pain and asks the client if they have had any prior surgeries. The client states that she had a hysterectomy 20 years ago. Why is this information relevant? Select all that apply. The information shows increased risk for obstructions The information shows increased risk for malabsorption The information rules out infection The information rules out appendicitis The information shows increased risk for adhesions
The information shows increased risk for adhesions The information shows increased risk for obstructions The information shows increased risk for malabsorption
A client's bladder is found to be distended. At which location would the nurse begin palpating? at the umbilicus at the symphysis pubis in the left lower quadrant in the right lower quadrant
at the symphysis pubis Explanation: The urinary bladder is located behind the symphysis pubis and rises above it when distended.
The nurse is taking the health history of a client who takes a calcium channel blocking medication for hypertension. The client reports a sensation of incomplete evacuation when having a bowel movement about three times per week. For which problem should the nurse further assess the client? pancreatic insufficiency clostridium difficile infection sigmoid colon lesion constipation
constipation
An older adult client who is admitted to the hospital with acute confusion has urinary incontinence. The nurse can accurately document this as which type of incontinence? urge functional stress overflow
functional Explanation: Functional incontinence can result from impaired cognition such as that which occurs with acute confusion. The older adult client may also have problems with mobility. This can also be a factor in identifying the type of incontinence as functional. Overflow incontinence is related to neurological disorders or anatomic obstructions from pelvic organs or prostate enlargement limit bladder emptying until the bladder becomes over-distended. Stress incontinence results from an increase in intra-abdominal pressure such as that caused by laughing. Urge incontinence results from the inability to hold urine due to detrusor over-activity causing decreased contractility of the urethral sphincter or poor support of the bladder neck.
The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation? discern muscular resistance identify abdominal organs complete a surface evaluation detect abdominal tenderness
identify abdominal organs
While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tinkling sounds throughout the distended abdomen. The nurse should refer the client to a health care provider for possible gastroenteritis. inflamed appendix. intestinal obstruction. cirrhosis of the liver.
intestinal obstruction. Explanation: Obstruction often presents with high-pitched tinkling sounds above the obstruction, in combination with distended abdomen; abdominal cramping is often present as well. Gastroenteritis may present with hyperactive bowel sounds that include tinkling, rushing, and high-pitched sounds and diarrhea is typical, but a distended abdomen is not typical. Cirrhosis of the liver may present with venous hum.
A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness? deep palpation percussion auscultation light palpation
light palpation Explanation: Light palpation aids in the detection of abdominal tenderness by allowing palpation without aggravating pain.
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. gastroenteritis. paralytic ileus. aortic aneurysm.
paralytic ileus. Explanation: Absent bowel sounds may be associated with peritonitis or paralytic ileus.
The colon originates in this abdominal area: the left upper quadrant. right upper quadrant. left lower quadrant. right lower quadrant.
right lower quadrant.
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's left upper quadrant. left lower quadrant. right lower quadrant. right upper quadrant.
right upper quadrant.
A nurse is describing viscera to a group of nursing students in the clinical area, differentiating solid viscera from hollow viscera. Which of the following would the nurse describe as hollow viscera? Select all that apply. liver gallbladder stomach pancreas small intestine urinary bladder
stomach gallbladder small intestine urinary bladder
A 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 pancreatic cancer. stomach ulcers. decreased gastric motility. abdominal tumors.
stomach ulcers. Explanation: Vomiting with blood (hematemesis) is seen with esophageal varices or duodenal ulcers.
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. listen in each quadrant for 15 seconds. begin auscultation in the left upper quadrant. palpate the abdomen before auscultation.
use the diaphragm of the stethoscope.
