Ch 23 - Assessing Abdomen

During deep palpation of the abdomen, a client experiences right lower quadrant rebound tenderness. The nurse should conduct which additional assessments? (Select all that apply.) A. Palpate for the Rovsing's sign. B. Assess for a Psoas sign. C. Assess for Murphy's sign. D. Assess for the Obturator sign. D. Test for a fluid wave.

A, B, D:Palpate for the Rovsing's sign; Assess for a Psoas sign; Assess for the Obturator sign. Additional techniques to assess for appendicitis after assessing rebound tenderness include Rovsing's sign, the psoas sign, the obturator sign. Assessment of the Murphy's sign is used when right upper quadrant pain is present. A positive Murphy's sign is indicative of acute cholecystitis. The fluid wave is used to assess for ascites.

The nurse explains to the client the main function of the stomach is to do what? Select all that apply. A. Store food B. Absorb nutrients C. Digest food D. Churn food E. Absorb salt and water

A, C, D: Store food; digest food; churn food The stomach's main function is to churn, store and digest food. The small intestine absorbs nutrients and the large intestine absorbs salt and water.

A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says A. "I can decrease the constipation if I eat foods high in fiber and drink water." B. "I should cut down on the number of iron tablets I am taking each day." C. "Constipation should decrease if I take the iron tablets with milk." D. "I should discontinue the iron tablets and eat foods that are high in iron."

A. "I can decrease the constipation if I eat foods high in fiber and drink water." High iron intake may lead to chronic constipation.

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

A. Abdominal bruit Auscultation of the abdomen would reveal a bruit. The client may exhibit decreased femoral pulses, hypotension and cool extremities.

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? A. Absent B. Hyperactive C. Borborygmus D. Erratic

A. Absent 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."

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

A. An enlarged liver felt during palpation The liver normally decreases in size after age 50 years. An enlarged liver needs further assessment. Appetite decreases with age due to altered metabolism, decreased taste sensation, decreased mobility, and possibly depression. Tympany is a normal finding over the stomach. The fluid wave test should be negative unless fluid (ascites) is present in the abdomen.

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? A. Appendicitis B. Inflammation of the gallbladder C. Liver engorgement D. Kidney pain

A. Appendicitis RLQ pain constitutes a positive obturator sign, suggesting an inflamed appendix or peritoneal inflammation. Kidney tenderness is assessed posteriorly. The Blumberg assesses for rebound tenderness and the Murphy test is for inflammation of the gallbladder.

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? A. Appendicitis B. Peritoneal irritation C. Liver inflammation D. Inflamed gall bladder

A. Appendicitis 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. Rebound tenderness occurs with peritoneal irritation. There is no specific sign for liver inflammation. Pain that occurs when pressure is applied under the liver border at the right costal margin indicates an inflamed gall bladder.

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? A. Bowel sounds normal. B. Bowel sounds hyperactive. C. Bowel sounds hypoactive. D. Bowel sounds inconsistent.

A. Bowel sounds normal. Normal bowel sounds consist of clicks and gurgles that occur at an estimated frequency of 5-34 per minute. The nurse should document that the bowel sounds are normal. Twenty bowel sounds in a minute is not hyperactive, hypoactive, or inconsistent.

The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what? A. Bruit B. Borborygmi C. Venous hum D. Friction rub

A. Bruit Bruits are swishing sounds that indicate turbulent blood flow. Borborygmi is increased bowel sounds. A venous hum is a soft-pitched humming sound associated with partial obstruction of an artery and reduced blood flow to the organ. Friction rubs are grating sounds with inspiration.

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? A. Crohn's disease B. Gastric ulcer C. Pancreatitis D. Gastroesophageal reflux

A. Crohn's disease 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.

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. Raise the client's arms or fold them behind the head C. Avoid the use of pillow under the head during examination D. Provide privacy to the client and instruct him to relax

A. Flex the client's legs by placing a pillow under the knees 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. Raising the client's arms above the head or folding them behind the head may tense the abdominal muscles. Placing a pillow under the client's head or providing privacy does not help in relaxing the abdominal muscles; however, these measures will provide comfort and relaxation to the client.

The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates? A. Inflammation of the gallbladder B. Appendicitis C. Kidney pain D. Peritonitis

A. Inflammation of the gallbladder Pain with breathing while assessing Murphy sign is an indication of inflammation of the gallbladder. Peritonitis is assessed for rebound tenderness, indicated by Blumberg sign (a sharp, stabbing pain as the examiner releases pressure from the abdomen). Kidney pain is assessed by performing blunt percussion at the costovertebral angles (CVA). Appendicitis is assessed with the iliopsoas muscle test.

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? A. Internal adhesions from previous surgery B. Intestinal obstruction at the sigmoid colon C. Acute onset of appendicitis with possible rupture D. Peritonitis from a ruptured diverticulum

A. Internal adhesions from previous surgery The key to this question is the presence of a 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. An intestinal obstruction would not produce a pulling feeling, but the client most likely would report nausea and vomiting. With a right lower quadrant scar, the appendix may already be removed. Acute appendicitis would also present with fever, nausea, and vomiting. Peritonitis would cause a rigid abdomen with generalized severe abdominal pain and fever.

A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ? A. Kidney B. Liver C. Spleen D. Gallbladder

A. Kidney The costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a kidney problem such as infection (pyelonephritis), renal calculi, or hydronephrosis. Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage & striking it with the ulnar side of the right fist. Percussion of the spleen begins in the left mid-axillary line & progresses downward until the sound changes from lung resonance to splenic dullness. The gallbladder is not percussed.

The nurse performs the technique shown when assessing a client. For what is this nurse assessing? A. Kidney tenderness B. Location of the spleen C. Nerve root compression D. Pain referred from the lungs

A. Kidney tenderness 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.

Your client 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 client? A. Malabsorption syndrome B. Lactose intolerance C. Crohn disease D. Ulcerative colitis

A. Malabsorption syndrome 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.

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

A. Middle of the ventral abdominal wall Four layers of large, flat muscles form the ventral abdominal wall and are joined at the midline by a tendinous seam, the linea alba. The lower edge of the costal margin and the anterosuperior iliac spine of the iliac bones are landmarks used to divide the abdomen into regions. The abdomen is a large cavity extending from the xiphoid process of the sternum down to the superior margin of the pubic bone.

Mr. Martin is a 72-year-old smoker who comes to the clinic for a follow-up visit for hypertension. With deep palpation a pulsatile mass about 4 cm in diameter is palpable. What should the examiner do next? A. Obtain abdominal ultrasound. B. Reassess by examination in 6 months. C. Reassess by examination in 3 months. D. Refer to a vascular surgeon.

A. Obtain abdominal ultrasound. A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 cm. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature.

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

A. Place left hand on right lower rib cage, strike it with ulnar side of right fist The correct way of performing blunt percussion is to place left hand on right lower rib cage, strike it with ulnar side of right fist. Placing the hand on the middle of rib cage would not enable the nurse to assess the liver. Placing the right hand on the rib cage and striking with radial side of left hand may not be technically possible.

A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness? A. light palpation B. deep palpation C. percussion D. auscultation

A. light palpation Light palpation aids in the detection of abdominal tenderness by allowing palpation without aggravating pain. Deep palpation requires that the nurse press down 5 to 8 cm (2 to 3 inches) which may cause the client further discomfort or pain. Deep palpation is warranted to delineate edges of abdominal organ masses. Percussion helps to assess the amount of gas throughout the abdominal viscera and masses that are solid or fluid filled. Auscultation allows the nurse to listen for bowel sounds.

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? A. place a small pillow under the client's knees B. raise the head of the bed to a 30-degree angle C. remove a pillow from behind the client's head D. assist to a sitting position with the legs dangling

A. place a small pillow under the client's knees A small pillow placed under the knees relaxes the abdominal musculature. The abdominal assessment should not be performed with the head of the bed raised to a 30-degree angle or sitting with the legs dangling. Removing a pillow from behind the client's head will make the abdominal muscles more tense.

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? A. right upper B. left upper C. right lower D. left lower

A. right upper The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal.

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's A. right upper quadrant. B. right lower quadrant. C. left upper quadrant. D. left lower quadrant.

A. right upper quadrant. The liver is located in the right upper quadrant. Percuss the span or height of the liver by determining its lower and upper borders. The lower border of liver dullness is located at the costal margin to 1 to 2 cm below. To assess the lower border, begin in the RLQ at the mid-clavicular line (MCL) and percuss upward.

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 A. stomach ulcers. B. pancreatic cancer. C. decreased gastric motility. D. abdominal tumors.

A. stomach ulcers. Vomiting with blood (hematemesis) is seen with esophageal varices or duodenal ulcers.

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? A. visceral B. parietal C. referred D. musculoskeletal

A. visceral Visceral pain in the right upper quadrant often suggests liver distension and may be related to alcohol hepatitis. Parietal pain originates from inflammation in the parietal peritoneum also known as peritonitis. Referred pain is felt in the more distant sites, which are innervated at approximately the same spinal levels as the body structure that is inflamed. Right upper quadrant pain is not related to or caused by any problems of the musculoskeletal system.

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? A. "What is the consistency of your stools?" B. "How many times a day are you having a bowel movement?" C. "Do you have a bowel movement every day?" D. "Have you changed your food intake this week?"

B. "How many times a day are you having a bowel movement?" Diarrhea is defined as frequency of bowel movements producing unformed or liquid stools. To determine whether the client is truly experiencing diarrhea, the nurse should ask about how many times a day the client is having a bowel movement. The other important question is how many times a day does the client normally have a bowel movement. The consistency will not tell the nurse whether this is normal or abnormal. Asking about food intake will give information about whether the client has tried to treat the problem.

The peritoneum is a serous membrane that contains which of the following? A. Antibodies B. A parietal layer C. A visceral ligament D. A drying agent

B. A parietal layer The peritoneum, mesentery, and muscles are also part of the abdominal cavity. The peritoneum is a serous membrane that covers and holds the organs in place. It contains a parietal layer that lines the walls of the abdomen and a visceral layer that coats the outer surface of the organs.

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? A. Uses the left arm for phlebotomy B. Attempts to palpate the spleen C. Orders a spiral computerized tomography (CT) scan D. Places a cervical collar on the client

B. Attempts to palpate the spleen 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 expect 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.

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? A. Avoid eating overcooked foods B. Avoid excessive alcohol intake C. Avoid taking pain medications with food D. Avoid taking antacid medications

B. Avoid excessive alcohol intake 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.

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? A. Ineffective Nutrition: Less Than Body Requirements B. Constipation related to decrease in fluid intake C. Ineffective Health Maintenance D. Risk for Fluid Volume Deficit

B. Constipation related to decrease in fluid intake 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.

What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen? A. Epigastric B. Hypogastric C. Hypochondriac D. Inogastric

B. Hypogastric The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right inguinal, hypogastric, and left inguinal.

When performing the abdominal assessment for a client, which assessment technique should the nurse perform first? A. Auscultation B. Inspection C. Percussion D. Palpation

B. Inspection The appropriate sequence for abdomen assessment is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion and palpation.

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? A. Peritoneum B. Linea alba C. Internal abdominal oblique D. Transverse abdominis

B. Linea alba The joining of the muscle fibers and aponeuroses at the midline of the abdomen forms a white line called the linea alba, which extends vertically from the xiphoid process of the sternum to the symphysis pubis. The abdomen includes three layers of muscle extending from the back, around the flanks, to the front. The outermost layer is the external abdominal oblique; the middle layer is the internal abdominal oblique; and the innermost layer is the transverse abdominis. A thin, shiny, serous membrane called the peritoneum lines the abdominal cavity (parietal peritoneum) and also provides a protective covering for most of the internal abdominal organs (visceral peritoneum).

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be? A. Upper abdomen B. Suprapubic C. Back D. Perineal

B. Suprapubic Bladder disorders may cause suprapubic pain.

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

B. The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Because the gallbladder is deep to the liver, it is normally not amenable to direct examination by auscultation, palpation, or percussion. This does not mean, however, that cholecystitis and cholelithiasis cannot be assessed for a thorough history. The gallbladder and the spleen are not proximate.

A client reports severe pain in the left lower quadrant of 3 days' duration. How should the nurse conduct palpation of the abdomen due to this history? A. This area should be avoided completely B. The left lower quadrant is palpated last C. Medicate for pain before beginning the assessment D. Encourage the client to relax to minimize pain

B. The left lower quadrant is palpated last The nurse should avoid touching tender or painful areas until last and reassure the client. The area needs to be assessed for the presence of abnormal findings and should not be avoided. Medicating before palpating may obscure the findings. The client may not be able to relax just by the power of suggestion.

During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document this finding? A. relieving factors B. associated manifestations C. characteristic symptoms D. onset

B. associated manifestations The nurse should document this finding in the associated manifestations section because this is a report on the experience of other symptoms associated with abdominal pain. In relieving factors, the nurse explores factors that aggravate or relieve the pain. In characteristic symptoms, the nurse should ask the client to describe the pain in his or her own words. Onset refers to when the abdominal pain started.

The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area? A. percussion B. auscultation C. light palpation D. deep palpation

B. auscultation Auscultate the abdomen before performing percussion or palpation because these maneuvers may alter the frequency of bowel sounds. After auscultation, the order of assessment should be percussion, light palpation, and conclude with deep palpation.

The sigmoid colon is located in this area of the abdomen: the A. left upper quadrant B. left lower quadrant C. right upper quadrant D. right lower quadrant

B. left lower quadrant The left lower quadrant (LLQ) contains the left kidney (lower pole), left ovary and tube, left ureter, left spermatic cord, and descending and sigmoid colon.

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the A. left lower quadrant. B. left upper quadrant. C. right upper quadrant. D. right lower quadrant.

B. left upper quadrant. The spleen is located in the left upper quadrant.

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 A. aortic aneurysm. B. paralytic ileus. C. gastroenteritis. D. fluid and electrolyte imbalances.

B. paralytic ileus. Absent bowel sounds may be associated with peritonitis or paralytic ileus.

A student nurse is performing a focused abdominal assessment of a hospitalized client. The nursing instructor determines proper assessment technique when the nursing student performs the assessment in what order? Place the steps in the correct order. A. Auscultation B. Percussion and palpation C. Inspection

C, A, B: Inspection, Auscultation, Percussion and palpation For an accurate assessment of the abdomen, the nurse must inspect first, then auscultate, percuss, and palpate. The abdominal assessment is completed in this order so as to not disrupt the patterns of the bowel sounds, which may provide incorrect information to the health care provider.

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 medical diagnosis is associated with the assessment finding? A. Gastroenteritis B. Liver disease C. Appendicitis D. Enlarged spleen

C. Appendicitis Rovsing's sign is an indicator of appendicitis. It is not a sign of gastroenteritis, liver disease, or an enlarged spleen.

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

C. Applying and releasing pressure to the abdomen 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.

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? A. Absent B. Hypoactive C. Borborygmus D. Erratic

C. 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 loud, prolonged gurgles characteristic of one's "stomach growling." Erratic is not a type of bowel sound.

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? A. Absent B. Hypoactive C. Borborygmus D. Erratic

C. 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 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? A. Document the absence of bowel sounds B. Assess for findings of dehydration C. Listen for a total of 5 minutes D. Palpate for abdominal rigidity

C. Listen for a total of 5 minutes 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. 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.

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. Auscultate for bowel sounds C. Measure abdominal girth D. Perform percussion for tympany

C. Measure abdominal girth The nurse should measure abdominal girth daily to assess changes in abdominal distension. Palpating and auscultating the abdomen may not given relevant information about peritonitis. Percussion for tympany may indicate presence of air but does not indicate improvement.

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. Have the client lying down in the bed with the head of bed slightly elevated B. Any time of day is acceptable when using the umbilicus as a starting point C. Measure at the same time each day, ideally in the morning after voiding D. Elevate the head of bed to concentrate the fluid in one area of the abdomen

C. Measure at the same time each day, ideally in the morning after voiding The umbilicus should be used as the starting point for measuring abdominal girth, especially when ascites is present. Measure the girth at the same time each day, ideally after the client voids in the morning. The ideal position is for the client to stand. If the client cannot stand, the supine position is acceptable. The head of the bed should be flat unless the client has difficulty breathing.

You are assessing a client for acute cholecystitis. What sign would you assess for? A. Psoas sign B. Obstipation sign C. Murphy sign D. Cutaneous hyperesthesia

C. Murphy sign A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.

Diagnostic tests completed validate that a client has an obstruction of the ascending and transverse colon. Where should the nurse assess for bowel sounds around the obstruction? A. Left upper quadrant B. Left lower quadrant C. Right upper quadrant D. Right lower quadrant

C. Right upper quadrant The right upper quadrant is used to assess for the ascending and transverse colon. The left upper quadrant is used to assess the transverse and descending colon. The left lower quadrant is used to assess the descending and sigmoid colon. The right lower quadrant is used to assess the ascending colon.

A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ? A. Kidney B. Liver C. Spleen D. Gall bladder

C. Spleen Percussion of the spleen begins in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness. 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 costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a kidney problem such as infection (pyelonephritis), renal calculi, or hydronephrosis. The gall bladder is not percussed.

The nurse is assessing an older adult client who has lost 2.27 kg (5 lb) since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for A. peptic ulcer. B. bulimia. C. appetite changes. D. pancreatic disorders.

C. appetite changes. Older adult clients may experience a decline in appetite from various factors such as altered metabolism, decreased taste sensation, decreased mobility, and, possibly, depression. If appetite declines, the client's risk for nutritional imbalance increases.

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should A. palpate the abdomen before auscultation. B. listen in each quadrant for 15 seconds. C. use the diaphragm of the stethoscope. D. begin auscultation in the left upper quadrant.

C. use the diaphragm of the stethoscope. Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client's abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants.

The nurse working in a clinic is assessing a 33-year-old male client. Select the findings that will require a follow-up. The client reports <<<recent increase in lethargy, and shortness of breath with activity>>>. The nurse performs a comprehensive assessment. Findings reveal <<<pale, cool skin; weak pulses bilaterally>>>; and <<<delayed capillary refill time>>>. Vital signs include: temperature, 97.7°F (36.5°C); <<<heart rate, 95 beats/min; blood pressure, 110/65 mm Hg; respiratory rate, 16 breaths/min>>>; <<<oxygen saturation, 93% on room air>>>. The client denies difficulty voiding but reports <<<dark, tarry stools for the past month>>>.

Correct answers: - recent increase in lethargy, and shortness of breath with activity - pale, cool skin; weak pulses bilaterally - delayed capillary refill time - oxygen saturation, 93% on room air - dark, tarry stools for the past month The client is experiencing signs and symptoms of a gastrointestinal bleed, which includes increased lethargy; shortness of breath; pale, cool skin; weak pulses; decreased capillary refill time; and dark, tarry stools. The client is experiencing shortness of breath due to loss of blood in the gastrointestinal tract causing a decrease in hemoglobin and a decrease in oxygen-carrying capacity. The client's pale, cool skin and weak pulses are the result of blood loss. The decreased capillary refill time is a result of decreased perfusion due to the loss of blood volume. The decrease in oxygen saturation, 93% on room air, is also a result of blood loss, which decreases hemoglobin and causes decreased oxygen-carrying capacity. The client's heart rate, blood pressure, and respiratory rate are all within normal limits.

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? A. Peptic ulcer disease B. Biliary colic C. Acute cholecystitis D. Acute pancreatitis

D. Acute pancreatitis 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.

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. Pancreatitis D. Appendicitis

D. Appendicitis 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.

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? A. Staphylococcus aureus B. Escherichia coli C. Streptococcus pyogenes D. Helicobacter pylori

D. Helicobacter pylori Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucous, on occassion the H. pylori disrupts the mucous lining and inflames the organ lining. The other bacteria listed are not associated with peptic ulcer disease.

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? A. Colon cancer B. Cholecystitis C. Inflammatory bowel disease D. Irritable bowel syndrome

D. Irritable bowel syndrome 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.

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? A. Encourage the client to increase PO fluid intake. B. Record the findings as expected for a client with an indwelling catheter. C. Flush the catheter tubing with sterile normal saline. D. Prepare to obtain a urine specimen for culture.

D. Prepare to obtain a urine specimen for culture. The client is exhibiting symptoms of a catheter associated urinary tract infection. The nurse should notify the healthcare provider and prepare to collect a urine specimen for culture. Increased fluid intake can decrease complications of a UTI; however, a UTI must be treated with antibiotics as well. Flushing the tubing with saline involves disrupting the sterility of the line and is not routinely performed when suspecting a UTI.

A nurse performs light palpation of the abdomen and feels a prominent, nontender, pulsating mass above the umbilicus that measures approximately 6 cm. What is an appropriate action by the nurse? A. Assist the client to the bathroom to empty the bladder B. Use percussion to determine the solidity of the structure C. Auscultate over the same area for the presence of a bruit D. Stop the palpation and notify the health care provider

D. Stop the palpation and notify the health care provider 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.

When inspecting the abdomen, which of the following client positions facilitates correct examination technique? A. Sitting with hands on hips B. Trendelenburg with hands over head C. Semi-Fowler's with pillows under head and knees D. Supine with arms at sides or folded across chest

D. Supine with arms at sides or folded across chest A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to sitting, Trendelenburg, or semi-Fowler's position.

The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the A. right upper quadrant. B. left upper quadrant. C. external oblique angle. D. costovertebral angle.

D. costovertebral angle. Kidney tenderness is best assessed at the costovertebral angle.

The pancreas of an adult client is located A. below the diaphragm and extending below the right costal margin. B. posterior to the left midaxillary line and posterior to the stomach. C. high and deep under the diaphragm and can be palpated. D. deep in the upper abdomen and is not normally palpable.

D. deep in the upper abdomen and is not normally palpable. The pancreas, located mostly behind the stomach deep in the upper abdomen, is normally not palpable. it is a long gland extending across the abdomen from the RUQ to the LUQ.

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 A. liver disease. B. abdominal disension. C. Cushing syndrome. D. internal bleeding.

D. internal bleeding. Purple discoloration at the flanks (Grey-Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.

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 A. gallbladder disease. B. cachexia. C. kidney trauma. D. masses.

D. masses. A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue.

A nurse is performing an admission assessment on a new client. The client reports black tarry stools and abdominal pain immediately after eating. What condition would the nurse suspect? A. Crohn's disease B. indigestion C. constipation D. peptic ulcer

D. peptic ulcer Peptic ulcer presents with abdominal pain immediately after eating (gastric ulcer) and possibly black tarry stools if bleeding is occurring. Signs and symptoms of Crohn's disease include weight loss and malnutrition. Indigestion, also referred to as GERD, presents with signs and symptoms of hyperacidity after eating large meals. Abdominal pain immediately after eating and black tarry stools are not signs and symptoms of constipation.

To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's A. left upper quadrant. B. left lower quadrant. C. right upper quadrant. D. right lower quadrant.

D. right lower quadrant. The appendix is located in the right lower quadrant.