Ch 23: assessing Abdomen

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? a) Localized pain b) Radiated pain c) Chronic pain d) Referred pain

d) Referred pain 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.

A nurse observes the abdomen of a client and notices it to be distended below the umbilicus. The nurse recognizes that this can be caused by which of these conditions? Select all that apply. a) Ovarian tumor b) Tumor of the kidney c) Uterine enlargement d) Pancreatic mass e) Full bladder f) Impacted colon

e) Full bladder, c) Uterine enlargement, a) Ovarian tumor, f) Impacted colon Abdominal distention below the umbilicus can be observed with a full bladder, uterine enlargement (tumor or pregnancy), ovarian cysts or tumors, and an impacted colon. A pancreatic tumor would be apparent in the upper abdomen. A tumor on the kidney would be apparent in the flank area.

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) May awaken the client at night b) Relieved by drinking water c) Increased by intake of food d) Throbbing in nature

a) May awaken the client at night A client with duodenal ulcers would have severe 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 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) Weight b) Activity level c) Height d) Food intake e) Urine output

a) Weight, d) Food intake 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 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) Gallbladder b) Liver c) Kidney d) Stomach e) Spleen

b) Liver, e) 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 percussed from the back & is not altered by an increase in intestinal gas.

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? a) Right lower quadrant b) Left upper quadrant c) Right upper quadrant d) Left lower quadrant

c) Right upper quadrant The liver is the largest solid organ in the body. It is located below the diaphragm in the right upper quadrant of the abdomen.

A client complains of a burning sensation in the esophagus after eating. Which associated condition should the nurse most suspect? a) Pancreatic cancer b) Gastric ulcer c) Acute pancreatitis d) Acid reflux

d) Acid reflux The onset of pain is a diagnostic clue to its origin. For example, acute pancreatitis produces sudden onset of pain, whereas the pain of pancreatic cancer may be gradual or recurrent. A client may have excessive gas after ingesting certain foods. A burning sensation in the esophagus may occur with gastric acid reflux after eating. Pain related to gastric ulcers may occur when the stomach is empty.

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) Elevate the head of bed to concentrate the fluid in one area of the abdomen 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) Measure at the same time each day, ideally in the morning after voiding

d) 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 bed should be flat unless the client has difficulty breathing.

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?

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 nurse is attempting to palpate the abdomen of a 6-year-old girl, but the girl is so ticklish that the nurse cannot proceed. Which of the following should the nurse do?

Place the client's hand under the nurse's hand for a few moments A ticklish client has trouble lying still and relaxing during the hands-on parts of the examination. Try to combat this using a controlled hands-on technique and by placing the client's hand under your own for a few moments at the beginning of palpation. Holding hands under warm water just before the hands-on examination is done to warm the hands. Draping the client's genital area is done for modesty. Adjusting the bed level would not help with ticklishness.

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 examination c) Provide privacy to the client and instruct him to relax d) Raise the client's arms or fold them behind the head

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.

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

c) Murphy's The gallbladder is located in the right upper quadrant 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.

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) Kidney b) Gallbladder c) Spleen d) Pancreas

d) Pancreas The pancreas is most likely to be the cause of the 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 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.

An older client presents with symptoms of pain on urinating. The nurse recognizes that older adults are at increased risk for urinary tract infections for which of the following reasons?

Decreased activity of protective bacteria in the urinary tract Older adult clients are prone to urinary tract infections because the activity of protective bacteria in the urinary tract declines with age. It is not established that older adults have poorer hydration or nutrition than younger adults. A higher fat-to-lean muscle ratio would not affect risk for urinary tract infections.

A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?

Gastric ulcer Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.

A nurse is working with an older client who has had diarrhea for the past week and is dehydrated. The nurse understands that older clients are especially at risk for potential complications with diarrhea due to which of the following factors?

Higher fat-to-lean muscle ratio Older adult clients are especially at risk for potential complications with diarrhea, such as fluid volume deficit, dehydration, electrolyte, and acid-base imbalances, because they have a higher fat-to-lean muscle ratio. It is not established that older adults have a tendency to have an inadequate fluid intake. An increased number of medications taken would not explain increased risk for potential complications with diarrhea, and neither would decrease sensitivity to pain.

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) Medicate for pain before beginning the assessment b) The left lower quadrant is palpated last c) Encourage the client to relax to minimize pain d) This area should be avoided completely

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.

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

c) An increase in the pitch An increase in the pitch of bowels 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 inspects a client's abdomen and notices that a bulge is present in the right lower quadrant. How should the nurse further assess this finding using inspection? a) Have the client cough forcefully a few times b) Palpate to measure the diameter of the mass c) Ask the client to raise the head off the bed d) Percuss to determine if the mass is fluid filled

c) Ask the client to raise the head off the bed Asking the client to raise the head off the bed will help the nurse to determine the location of the mass. A mass within the abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is obscured. Palpation and percussion should come after inspection is completed. Coughing will not assist the nurse with assessment of the abdominal mass.

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) Bleeding b) Obstruction c) Fluid accumulation d) Inflammation

c) Fluid accumulation 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.

A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ? a) Gallbladder b) Liver c) Spleen d) Kidney

d) 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.

A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause?

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

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

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

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) Constipation related to decrease in fluid intake b) Risk for Fluid Volume Deficit c) Ineffective Nutrition: Less Than Body Requirements d) Ineffective Health Maintenance

a) 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.

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

d) 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.

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) Peritonitis from a ruptured diverticulum c) Acute onset of appendicitis with possible rupture d) Intestinal obstruction at the sigmoid colon

a) Internal adhesions from previous surgery 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. 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 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) Hyperactive b) Absent c) Erratic d) Borborygmus

b) 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."

When performing the abdominal assessment for a client, which assessment technique should the nurse perform first? a) Auscultation b) Inspection c) Palpation d) Percussion

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.

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

b) Obturator The test indicates a positive obturator 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 for assessment of 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.

A nurse assesses a client with a distended abdomen. Which action by the nurse demonstrates the correct way to assess the client for ascites? a) Inspect the abdominal skin for vascularity and striae b) Percuss the flanks from bed upward toward the umbilicus c) Auscultate for bowel sounds in all quadrants of abdomen d) Palpate the abdomen lightly for areas of tenderness

b) Percuss the flanks from bed upward toward the umbilicus The nurse should test for shifting dullness by percussing the flanks from bed upward toward the umbilicus to assess for ascites. Auscultating for bowel sounds in all quadrants of abdomen may not give any indication about ascites. Inspecting the abdominal skin for vascularity and striae may indicate ascites but it does not confirm the presence of fluids. Palpating the abdomen lightly for areas of tenderness may not contribute to ascites assessment.

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

b) Place the tape measure behind the client and measure at the umbilicus The nurse should place the tape measure behind the client and measure at the umbilicus. The umbilicus should be the starting point when measuring the abdomen especially when distention is apparent. Abdominal measurement is generally taken in the morning after voiding, not after the client has had a full meal. The ideal position to measure the abdomen is standing not sitting. The nurse informs the client that the pen mark on the abdomen should not be washed out only if the client is being monitored on a regular basis to determine progress of treatment for abdominal distention.

A student nurse is auscultating for bowel sounds on a client who returned from surgery 48 hours ago. The student tells the charge nurse that she cannot hear bowel sounds in the lower quadrants. What is the appropriate response by the charge nurse to this information? a) "The nasogastric tube is preventing you from hearing the bowel sounds correctly." b) "You need to call the health care provider immediately for orders." c) "It takes about 3 to 5 days after surgery for the bowel sounds to return completely." d) "Did you listen for 5 minutes in all four quadrants of the abdomen?"

c) "It takes about 3 to 5 days after surgery for the bowel sounds to return completely." Bowel sounds will return gradually after surgery, the timing depending on the location of the surgery. The small intestine functions normally in the first few hours postoperatively; stomach emptying takes 24 to 48 hours; and the colon can take 3 to 5 days to recover. There is no need to call the health care provider because there is no need for intervention. Listening longer is not necessary because the client is 48 hours postoperative and the colon is not functioning yet. A nasogastric tube does not stop the bowel from working, but is used in the event the client experiences nausea.

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? a) Obtain a complete set of vital signs and pain assessment b) Observe for evidence of increased abdominal girth c) Listen with the bell of the stethoscope for vascular sounds d) Inspect the abdomen for color, shape, and symmetry

c) Listen with the bell of the stethoscope for vascular sounds A client with a history of hypertension is at risk for bruits over any of the vascular areas on the abdomen such as renal artery, iliac artery, or femoral artery. The bell of the stethoscope is used for this assessment because bruits are low-pitched, murmur-like sounds. Inspection of the abdomen should be performed before auscultation. Vital signs are part of the general survey and are usually the first hands-on assessment of a client. Measuring abdominal girth is done if the nurse observes a distended abdomen or there are other signs of fluid retention within the abdomen.

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 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 ulnar side of right fist d) Place left hand on right lower rib cage, strike it with radial side of right fist

c) 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 mid 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 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) "Do you have a bowel movement every day?" b) "What is the consistency of your stools?" c) "Have you changed your food intake this week?" d) "How many times a day are you having a bowel movement?"

d) "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.

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 regards to this finding? a) "Have you noticed any color change to the skin?" b) "Are you experiencing any abdominal pain?" c) "Do you have high blood pressure?" d) "How many times have you been pregnant?"

d) "How many times have you been pregnant?" Striae are silvery white marks that are common on the abdomen from stretching of the skin during pregnancy or weight gain. They do not cause pain or any other color changes to the skin. High blood pressure may cause the dilation of the superficial arterioles or capillaries with a central star pattern (spider angioma) but would not result in striae.

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) Transverse abdominis b) Internal abdominal oblique c) Peritoneum d) Linea alba

d) 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).

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) Palpate for abdominal rigidity b) Document the absence of bowel sounds c) Assess for findings of dehydration d) Listen for a total of 5 minutes

d) 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.