Ch. 23 Abdomen

A nurse receives an order to measure the abdominal girth daily on a client admitted with ascites. How should the nurse best implement this order? a) measure at the same time each day, ideally in the morning after voiding b) any time of day is acceptable when using the umbilicus as a starting point c)have the client lying down in the bed with the head of bed slightly elevated d) elevate the head of bed to concentrate the fluid in one area of the abdomen.

A

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? a) place the tape measure behind the client and measure at the umbilicus b)inform the client that the pen mark on the abdomen should not be washed off c) ask the client to be seated and relaxed when taking the measurement d) ensure the client has had a full meal before measuring the abdomen.

A

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen? a) flex the client's legs by placing a pillow under the knees b)Avoid the use of pillow under the head during the examination c) provide privacy to the client and instruct him to relax d) raised the client's arms or fold them behind the head.

A

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? a) Murphy's b) Obturator c)Psoas d) Rovsing's

A The gallbladder is located in the RUQ of the abdomen. When it is inflamed (cholecystitis), performing the Murphy's sign will cause the client to hold the breath (inspiratory arrest). The Obturator & Psoas tests are to determine if the appendix is inflamed. Rovsing's sign test for rebound tenderness which may indicate peritoneal irritation.

Which change in auscultation of bowel sounds should the nurse recognize as most diagnostic of an intestinal obstruction? a) an increase in pitch b)increase in the frequency of gurgles c) a soft click every 5-15 seconds d)no sound heard in one minute

A- An increase in pitch of bowel sounds is most diagnostic of obstruction because it signifies intestinal distention. A soft click or gurgle every 5-15 seconds is normal. An increase in the frequency of bowel sounds can be normal and is characteristic of stomach growling. Bowel sounds should be auscultated for 5 minutes to confirm their absence.

A nurse assess a client with a distended abdomen. Which action by the nurse demonstrates the correct way to assess the client for ascites? a)auscultate for bowel sounds in all 4 quad. b)percuss the flanks from bed upward toward the umbilicus c)palpate the abdomen lightly for areas of tenderness d)inspect the abdominal skin for vascularity and striae

B

A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement? a) palpate the abdomen b)measure the abdominal girth c) perform percussion for tympany d) auscultate for bowel sounds

B

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 appropriate action by the nurse? a)document the absence of bowel sounds b) listen for a total of 5 minutes c) assess for findings of dehydration d)palpate for abdominal rigidity

B Bowel sounds normally occure 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. Assessing the client for dehydration is necessary but not in relation to the finding of bowel sounds. Palpation should be done after completing auscultation of the abdomen.

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? a)inflammation b)fluid accumulation c) bleeding d)obstruction

B Pale and taut skin indicates 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.

A nurse cares for a client with a duodenal ulcer. The nurse knows that which characteristic of pain is generally associated with the client's condition? a) throbbing in nature b) may awaken the client at night c) relieved by drinking water d) increased by intake of food

B A client with duodenal ulcers would have sever pain that awakens him at night. The pain may not increase by the intake of food but may be relieved by it. The pain is unrelated to drinking water. The nature of the pain may vary and may not necessarily be throbbing.

A nurse performs light palpation of the abdomen and feels prominent, nontender, pulsating mass above the umblicius that measures approximately 6cm. What is an appropriate action by the nurse? a) assist the client to the bathroom to empty the bladder b) stop the palpation and notify the healthcare provider c) auscultate over the same area for the presence of a bruit d)use percussion to determine the solidity of the structure

B A pulsating abdominal mass may indicate the presence of an abdominal aortic aneurysm. An aneurysm is an area within a vessel where the wall of the vessel becomes weak, engorged with blood, and may rupture. The nurse should stop palpating immediately and notify the health care provider. This client may need to go to surgery for repair of the aneurysm. All other options are not safe or indicated for this client at this time.

A nurse examines a client with a paralytic ileus. Which alternation in bowel sounds should the nurse expect to find with auscultation of the client's abdomen? a)erratic b)absent c)borborygmus d)hyperactive

B The nurse should find that bowel sounds are absent. Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds. Hyperactive bowel sounds may be due to surgery or late bowel obstruction. Hyperactive bowel sounds referred to as " borborygmus" may also be heard. These are loud, prolonged gurgles characteristic of one's "stomach growling."

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? a) Rovsing's b) obturator c)Psoas d)Murphy's

B The test indicates a positive sign, which is performed to assess for appendicitis. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Murphy's sign is assessment for cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.

How should the nurse perform blunt percussion over the liver? a) place right hand on mid of the rib cage;strike it with ulnar side of left fist b)place left hand on right lower rib cage; strike with radial side of right fist c)place left hand on right lower rib cage; strike it with ulnar side of right fist d)place the right hand on mid of the rib cage; strike it with ulnar side of the left fist.

C

A client reports the onset of pain in the left upper quadrant of the abdomen with the ingestion of alcohol. The nurse recognizes that alteration in function of which organ is most likely to be the cause of this pain. a)spleen b)gallbladder c)pancreas d) kidney

C The pancreas is most likely to be the cause of pain in the left upper quadrant with ingestion of alcohol because chronic use causes inflammation of this organ. The gallbladder is in the right upper quadrant. The kidney and spleen are not affected by alcohol ingestion.

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)height b)urine output c)weight d)food intake e)activity level

C, D Appetite changes should be carefully correlated with dietary history and weight changes. Height is not affected by appetite. The client's urine output and activity level can be altered for many other reasons.

A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ? a) spleen b)liver c)gallbladder d) kidney

D

When performing the abdominal assessment for a client, which assessment technique should the nurse perform first? a) percussion b)auscultation c)palpation d)inspection

D

Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause? a)negative fluid wave test b)tympany percussed over the stomach c)report of a decrease in appetite d)an enlarged liver felt during palpation

D

A client reports the feeling of increased gas in the abdomen. The nurse recognizes that which organs may be difficult to percuss due an increase in air or intestinal gas? Select all that apply. a) kidney b)liver c)spleen d)gallbladder e)stomach

b)liver c)spleen An increase in intestinal gas makes percussion of the liver and spleen more difficult. The stomach is already filled with air so this will not change the ability to percuss the organ. Gallbladder is not usually percussed. The kidney is precussed from the back and is not altered by an increase in intestinal gas.