Health Assessment - Chapter 13: Abdomen and Gastrointestinal System
Nephrolithiasis
The formation of stones in the kidney pelvis. Factors contributing may be metabolic, dietary, genetic, or climatic. Urinary stasis and infection are important variables in the development and stones.
What questions does a nurse ask a patinet with a history of pancreatitis who is complaining of abdominal pain? a. Which foods aggravate the pain? b. Have you recently traveled outside the United State? c. Have you noticed a change in your bowel habits? d. How severe is the pain on a scale of 0 to 10?
d. How severe is the pain on a scale of 0 to 10?
What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient? a. Bowel sounds b. Venous hum c. Soft, low-pitched murmur d. No sounds
d. No sounds
Which patient has the lowest risk for colon cancer? a. Patient A is 50 years old, is obese, and has type 2 diabetes mellitus. b. Patient B is 60 years old, has alcoholism, and smokes a pack of cigarettes daily. c. Patient C is 55 years old, has ulcerative colitis, and inflammatory bowel disease. d. Patient D is 45 years old and has diverticulosis.
d. Patient D is 45 years old and has diverticulosis.
The patient reports right lower quadrant (RLQ) pain that is worse with coughing. Based on the patient's history, the nurse suspects appendicitis. What additional examination technique does the nurse perform to confirm this suspicion? a. Placing the hand over the lower right thigh and asking the patient to flex the knee while pushing down on the knee to resist it and noting if the patient complains of pain b. Palpating deeply a point of the abdomen, located halfway between the umbilicus and the left anterior iliac crest c. Asking the patient to flex the right hip and knee to 90 degrees, then abducting the leg and noting if the patient complains of pain d. Pressing down in an area away from the RLQ at a 90-degree angle to the abdomen, then releasing the fingers quickly and noting any complaint of pain
d. Pressing down in an area away from the RLQ at a 90-degree angle to the abdomen, then releasing the fingers quickly and noting any complaint of pain
When inspecting a patient's abdomen, which finding does the nurse note as normal? a. Engorgement of veins around the umbilicus b. Sudden bulge at the umbilicus when coughing c. Visible peristalsis in all quadrants d. Silver-white striae extending from the umbilicus
d. Silver-white striae extending from the umbilicus
Ascites
Movement of the area of dullness as the patient shifts position reflects the shift of fluid in the peritoneal cavity.
Nephrolithiasis
Signs include fever and hematuria. A symptom is flank pain that may radiate to the groin and genitals.
McBurney's Sign
A test for appendicitis.
Hiatal Hernia
A protrusion of the stomach through the esophageal hiatus of the diaphragm into the mediastinal cavity. Muscle weakness is a primary factor developing this type of hernia.
Alcoholism increases the risk of cancers of the gastrointestinal tract. Which cancer risk is increased in patients with alcoholism? Select all that apply. a. Esophageal cancer b. Stomach cancer c. Pancreatic cancer d. Liver cancer e. Colon cancer f. Bladder cancer
A, B, D, E
Pancreatitis
Acute or chronic inflammation from autodigestion.
Peptic Ulcer Disease
An ulcer occurring in the lower end of the esophagus in the stomach, or in the duodenum. Duodenal ulcer is the most common form, caused by abreak in the duodenal mucosa that scars without healing. Gastric and duodenal ulcers may result from infection with HElicobacter pyloria. Gastric ulcers are also caused by stress and medications such as corticosteroids, aspirin, and NSAIDS.
Shifting Dullness
Ask the patient to lie supine so any fluid pools in the lateral (flank) area. Percuss the abdomen. Draw lines on the abdomen. Draw lines on the abdomen to indicate the midline tympany (the expected tone) in contrast to lateral dullness (tone created by fluid). Then have the patient turn to the right side and repeat percussion. Listen for the tympanic tone to shift to the upper (left) side and the area of dullness rises toward the midline. Finally have the patient turn to the left lateral position and percuss. Listen as the dullness rises toward the midline.
A nurse suspects appendicitis in a patient with abdominal pain. Which findings are suggestive of appendicitis? Select all that apply. a. Pain radiating to the right shoulder b. Pain around the umbilicus c. Pain relieved by lying still d. Right lower quadrant pain e. Increased peristalsis
B, C, D
Pancreatitis
Can be caused by alcoholism or obstruction of the sphincter of Oddi by gallstones.
Hiatal Hernia
Clinical manifestations are the same as those of GERD: heartburn, regurgitation, and dysphagia.
Viral Hepatitis
Common symptoms are anorexia, vague abdominal pain, nausea, vomiting, malaise, and fever. An enlarged liver and spleen are classic findings. Jaundice, tan-colored stools, and dark urine may also be reported or observed.
Pylonephritis
Infection of the renal pelvis.
Urethritis
Infection of the urethra.
Cystitis
Infection of the urinary bladder.
Gastroesophageal Reflux (GERD)
Flow of gastric secretions into the esophagus. It is caused by weakening of the lower esophageal sphincter or increased intrabdominal pressure.
Steatorrhea
Greater than expected fat in the stool.
Diverticulitis
Inflammation of diverticula. Diverticula are herniations through the muscular wall in the colon. Presence of fecal material through the thin-walled diverticula causes inflammation and abscesses.
Cholecystitis
Inflammation of the gallbladder.
Viral Hepatitis
Inflammation of the liver results from different viruses.
Tympany
Is the most common percussion tone heard and is caused by the presence of gas. The suprapubic area may be dull when the urinary bladder is distended.
Ballottement
Palpation technique used to determine a floating mass. Can be performed with one or both hands.
Diverticulitis
Patients complain of cramping pain in the left lower quadrant; nausea; vomiting; and altered bowel habits, usually constipation. The abdomen may be distended and tympanic, with decreased bowel sounds and localized tenderness.
Gastroesophageal Reflux (GERD)
Patients complain of heartburn, regurgitation, and dysphagia (difficulty swallowing), which are aggravated by lying down and relieved by sitting up, antacids, and eating.
Pancreatitis
Patients complain of pain, described as steady, boring, dull, or sharp, that radiates from the epigastrium to the back. Patients prefer the fetal position with knees to the chest. Other manifestations include nausea and vomiting, weight loss, steatorrhea (greater than expected fat in the stool), and glucose tolerance.
Chron's Didsease
Patients complain of severe abdominal pain, cramping, diarrhea, nausea, fever, chills, weakness, anorexia, and weight loss.
Ulcerative Colitis
Patients complain of severe abdominal pain, fever, chills, anemia, and weight loss. The patient experiences profuse water diarrhea of blood, mucus, and pus.
Peptic Ulcer Disease
Patients with gastric ulcers complain of burning pain in the left epigastrium and back 1 to 2 hours after eating. Patients with duodenal ulcers complain of burning pain 2 to 4 hours after eating and at midmorning, at midafternoon, and in the middle of the night, with pain relief after taking antacids or eating.
Pylonephritis
Patients with the infection complain of flank pain, dysuria, nocturia, and frequency. Manifestations in older adults include confusion or delirium with or without fever.
Urethritis
Symptoms include frequency, urgency, and dysuria.
Cystitis
Symptoms include frequency, urgency, dysuria, plus sighs of bacteriuria and perhaps fever.
Cholecystitis with Cholelithiasis
The bile duct becomes obstructed by either edema from inflammation or gallstones.
Ulcerative Colitis
The chronic IBD starts in the rectum and progresses through the large intestine. The submucosa becomes engorged, and mucosa becomes ulcerated and denuded with granulation tissue; it may progress to colon cancer.
Cirrhosis
The liver becomes palpable and hard. Associated signs include ascites, jaundice, cutaneous spider angiomas, dark urine, tan colored stools, and spleen enlargement. End-stage is characterized by portal hypertension, esophageal varies, hepatic encephalopathy, and coma.
Obturator Muscle Test
The patient lies supine and flexes the right hip and knee to 90 degrees. Holding the leg just above the knee and at the ankle, the nurse rotates the leg medially and laterally.
Fluid Wave
The patient lies supine. You need the hand of another nurse or the patient to be placed sideways in the middle of the patient's abdomen to stop the transmission of a tap across the skin. Place your hands on either side of the abdomen. Use your fingertips to sharply strike one side of the abdomen. Feel for the fluid wave with the other hand on the opposite side of the abdomen.
Cholecystitis with Cholelithiasis
The primary symptom is right upper quadrant colicky pain that may radiate to midtorso or right scapula. Other indications include indigestion and mild transient jaundice.
A nurse expects which finding when assessing the abdomen of a patient who has been unable to void for 12 hours? a. Absent bowel sounds b. Hyperactive bowel sounds c. Tympanic tones over the lower abdomen d. Dull tones over the suprapubic area
d. Dull tones over the suprapubic area
Chron's Disease
This chronic inflammatory bowel disease (IBD) s also called regional enteritis or regional ileitis. Inflammation may occur from mouth to anus, but it commonly affects the terminal ileum and colon. Affected mucosa is ulcerated, with presence of fistulas, fissures, and abscesses that may form adjacent to healthy bowel segments.
Cirrhosis
This condition is a chronic obstructive degenerative disease of the liver in which diffuse destruction and regernation of hepatic parenchymal cells occur. Causes of this condition include viral hepatitis, biliary obstruction, and alcohol abuse.
Rebound Tenderness
This is present if the patient experiences more pain when pressure is released than when pressure is exerted and indicates peritoneal inflammation.
McBurney's Point
This should be palpated, located halfway between the umbilicus and the right anterior iliac crest. Press firmly into the abdomen and release pressure quickly.
Illiopsoas Muscle Test
With the patient supine, place your hand over the lower right thigh. Ask the patient to raise the right leg, flexing at the hip. Push down to resist the raising of the leg.
Obturator Muscle Test
When a ruptured appendix or pelvic abscess is suspected, this test should be performed.
Illiopsoas Muscle Test
When acute appendicitis is suspected, this test should be performed.
Cholelithiasis
When gallstones are present.
A patient reports a change in the usual pattern of urination. What question does the nurse ask to determine if incontinence is the reason for these symptoms? a. "Do you have the feeling that you cannot wait to urinate?" b. "Are you urinating a large amount each time you go to the bathroom?" c. "Has the color of your urine changed lately?" d. "Have you noticed any swelling in your ankles at the end of the day?"
a. "Do you have the feeling that you cannot wait to urinate?"
What instructions does the nurse give a patient before palpating the abdomen? a. Bend the knees. b. Take a deep breath and hold it. c. Take a deep breath and cough. d. Place the hands over the head.
a. Bend the knees.
A patient tells the nurse, "I've been having pain in my belly for several days that gets worse after eating." Which datum from the symptom analysis is consistent with the nurse's suspicion of peptic ulcer disease? a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating. b. Sharp midepigastric pain radiates to the jaw. c. Intermittent cramping pain in the left lower quadrant is relieved by defecation. d. Colicky pain is felt near the umbilicus with vomiting and constipation.
a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating.
The nurse recognizes which clinical finding as expected on palpation of the abdomen? a. Inability to palpate the spleen b. Left kidney rounded at 2 cm below the costal margin c. Slight tenderness of the gallbladder on light palpation d. Bounding pulsation of the aorta over the umbilicus
a. Inability to palpate the spleen
The nurse palpates the abdomen to gather data about which organs located in the right upper quadrant? a. Liver and gallbladder b. Stomach and spleen c. Uterus, if enlarged, and right ovary d. Right ureter and ascending colon
a. Liver and gallbladder
The nurse is interviewing a patient with a history of flank pain, fever, chills, and pain radiating to the groin. Which examination technique is most appropriate for this patient? a. Percussion of the costrovertebral angle b. Deep palpation of the abdomen c. Testing for rebound tenderness d. Auscultation of all quadrants of the abdomen
a. Percussion of the costrovertebral angle
A nurse notices abdominal distention when inspecting a patient's abdomen. What action does the nurse take next to gain further objective data? a. Place a measuring tape around the superior iliac crests. b. Assist the patient to turn on to the left side and then the right side. c. Ask the patient to cough while lying supine. d. Use the fingertips to sharply strike one side of the abdomen.
a. Place a measuring tape around the superior iliac crests.
On palpation of the left upper quadrant of the abdomen of a female patient, the nurse notes tenderness. This finding may indicate a disorder in which organ? a. Spleen b. Gallbladder c. Sigmoid colon d. Left ovary
a. Spleen
Which sound does a nurse expect to hear when percussing a patient's abdomen? a. Tympany over all quadrants b. Resonance over the upper quadrants and tympany in the lower quadrants c. Dull sounds over the upper quadrants and hollow sounds over the lower quadrants d. Dull sounds over the stomach and resonant sounds over the bladder
a. Tympany over all quadrants
In assessing a patient with renal disease, the nurse palpates edema in both ankles and feet. Based on this finding, what question does the nurse ask the patient? a. "Have you had any pain in your abdomen?" b. "Have you had an unexpected weight gain?" c. "Have you noticed a change in the color of your skin?" d. "Have you had any nausea or vomiting?"
b. "Have you had an unexpected weight gain?"
A patient reports having abdominal distention. The nurse notices that the patient's sclerae are yellow. What question is appropriate for the nurse to ask in response to this information? a. "Has there been a change in your usual pattern of urination?" b. "Have you had any nausea or vomiting?" c. "Has there been a change in your bowel habits?" d. "Have you had indigestion or heartburn?"
b. "Have you had any nausea or vomiting?"
During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis? a. "Have you noticed any swelling in your ankles or feet at the end of the day?" b. "Have you noticed a change in the color of your urine or stools?" c. "Have you vomited up any blood in the last 24 hours?" d. "Have you experienced fever, chills, or sweating?"
b. "Have you noticed a change in the color of your urine or stools?"
A 50-year-old patient asks how he can reduce the risk of colon cancer. What is the most appropriate response by the nurse? a. "A diet high in animal protein reduces the risk" b. "Regular exercise to reduce body fat helps prevent colon cancer" c. "Taking antacids for heartburn can help prevent colon cancer" d. "Taking vitamin C daily helps reduce the risk"
b. "Regular exercise to reduce body fat helps prevent colon cancer"
What technique does a nurse use when performing deep palpation of a patient's abdomen? a. Places the left hand under the ribs to lift them up b. Asks the patient to breathe slowly through the mouth c. Positions the patient on the right side with knees flexed d. Uses the heel of the hand to depress the abdomen
b. Asks the patient to breathe slowly through the mouth
A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next? a. Palpate lightly for tenderness and muscle tone. b. Auscultation for bowel sounds c. Palpate deeply for masses or aortic pulsation. d. Percuss for tones.
b. Auscultation for bowel sounds
Which location does a nurse select when palpating a patient's liver? a. A (right lower quadrant) b. B (right upper quadrant) c. C (left upper quadrant) d. D (left lower quadrant)
b. B (right upper quadrant)
A patient reports having abdominal distention. The nurse observes that the patient's sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patient's abdomen? a. Decreased bowel sounds in all quadrants b. Glistening or taut skin of the abdomen c. Bulge in the abdomen when coughing d. Bruit around the umbilicus
b. Glistening or taut skin of the abdomen
How does the nurse accurately assess bowel sounds? a. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant. b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant. c. Press the bell of the stethoscope firmly against the abdomen in each quadrant. d. Hold the bell of the stethoscope lightly against the abdomen in each quadrant.
b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant.
When assessing a patient's abdomen, the nurse uses assessment techniques in which order? a. Inspection, palpation, percussion, and auscultation b. Insepction, ausculation, palpation, and percussion c. Auscultation, inspection, percussion, and palpation d. Palpation, auscultation, inspection, and percussion
b. Insepction, ausculation, palpation, and percussion
When inspecting a patient's abdomen, the nurse notes which finding as abnormal? a. Protruding abdomen with skin that is lighter in color than the arms and legs b. Marked rhythmic pulsation to the left of the midline c. Faint, fine vascular network d. Small shadows created by changes in contour
b. Marked rhythmic pulsation to the left of the midline
When assessing the abdomen of a patient who has fluid in the peritoneal cavity, the nurse expects what change to occur when the patient turns from supine to the left side? a. Movement of the tympanic tones from lateral in the supine position to closer to midline when lying on the left side b. Movement of the dull tones from lateral in the supine position to closer to midline when lying on the left side c. Change in bowel sounds from hypoactive in the supine position to hyperactive when lying on the left side d. Change in bowel sounds from hyperactive in the supine position to hypoactive when lying on the left side
b. Movement of the dull tones from lateral in the supine position to closer to midline when lying on the left side
A patient reports a gnawing, burning pain in the mid-epigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask for the symptom analysis? a. "Do you have a family history of this type of pain?" b. "How long ago did you eat?" c. "Do you have any symptoms such as nausea with this pain?" d. "Have you noticed any yellow coloring in your eyes or on your skin?"
c. "Do you have any symptoms such as nausea with this pain?"
A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? a. "Has there been a change in your usual pattern of urination?" b. "Did you have heartburn before the vomiting?" c. "What did the vomitus look like?" d. "Have you noticed a change in the color of your urine or stools?"
c. "What did the vomitus look like?"
A 75-year-old male patient asks how to reduce his risk of esophageal cancer. What is the nurse's most appropriate response? a. "Don't worry about it, esophageal cancers have a low incidence in men." b. "You should not be concerned about esophageal cancer at your age." c. "You should consider limiting your alcohol intake to two drinks per day." d. "Increasing the fiber and protein in your diet can help you lower your risk."
c. "You should consider limiting your alcohol intake to two drinks per day."
When palpating the abdomen to determine a floating mass, a nurse presses on the abdomen at a 90-degree angle with the fingertips. Which finding indicates a mass? a. An increase in abdominal girth b. A complaint from the patient of a dull pain in the flank area c. A freely movable mass will float upward and touch the fingertips d. Fluid in the abdomen will shift upward and touch the fingertips
c. A freely movable mass will float upward and touch the fingertips
Which techniques does a nurse use to palpate a patient's right kidney? a. Asks the patient to take a deep breath, elevates the patient's eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand b. Asks the patient to exhale, elevates the patient's eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand c. Asks the patient to take a deep breath, elevates the patient's right flank with the left hand, and deeply palpates for the right kidney with the right hand d. Asks the patient to exhale, elevates the patient's right flank with the left hand, and deeply palpates for the right kidney with the right hand
c. Asks the patient to take a deep breath, elevates the patient's right flank with the left hand, and deeply palpates for the right kidney with the right hand
The nurse observes a patient rocking back and forth on the examination table in pain. Based on the patient's history, the nurse suspects kidney stones. What additional examination technique does the nurse perform to confirm this suspicion? a. Palpating the flank area for rebound tenderness b. Percussing the bladder for fullness c. Percussing the costal vertebral margins for tenderness d. Palpating McBurney point for tenderness
c. Percussing the costal vertebral margins for tenderness
A nurse performing an abdominal examination on a 37-year-old woman would document which findings as abnormal? a. Nonpalpable speen or kidneys b. Bowel sounds every 15 seconds in the lower quadrants c. Buldges observed when coughing d. Silver-white striae and a faint vascular network
c. Buldges observed when coughing
On inspection of a female patient's abdomen, the nurse asks the patient to raise her head without using her arms and notes a midline bulge. What is the appropriate response of the nurse at this time? a. Ask the patient to cough to see if the bulge reappears. b. Auscultate the patient's abdomen for hypoactive bowel sounds. c. Document this as a normal finding and continue the examination. d. Perform light and deep palpation of the abdomen.
c. Document this as a normal finding and continue the examination.
Which is an expected finding of an abdominal examination of an adult? a. Dull-percussion tones over the bladder b. Venus hum over the epigastrium on auscultation c. High-pitched gurgles every 5 to 15 seconds on auscultation d. Swishing sounds over the abdominal aorta on auscultation
c. High-pitched gurgles every 5 to 15 seconds on auscultation
A patient reports intermittent cramping abdominal pain that is relieved by having a bowel movement. The patient complains of having the pain at this time, which is why she is seeking care. Which abnormal finding does the nurse anticipate finding on examination of this patient's abdomen? a. Decreased bowel sounds b. Bulge in the abdomen when coughing c. Palpable mass in the left lower quadrant d. Bruit around the umbilicus
c. Palpable mass in the left lower quadrant
The nurse suspects that the patient has appendicitis. Which assessment techniques can the nurse use to confirm his or her suspicion? a. Gently perform fist percussion over the right costoverebral angle b. Ask the patient to place her hand on the abdomen while the nurse taps one side of the abdomen and palpates the other side c. Palpate the left lower quadrant at a 90-degree angle and quickly release his or her hand d. With the patient lying supine and flexing her right knee and hip, tap on the sole of the patient's right foot
c. Palpate the left lower quadrant at a 90-degree angle and quickly release his or her hand
When assessing an adult's liver, the nurse percusses the lower border and finds it to be 5 cm below the costal margin. What is the nurse's appropriate action at this time? a. Document this as an expected finding for this adult. b. Palpate the gallbladder for tenderness. c. Palpate the upper liver border on deep inspiration. d. Use the hooking technique to palpate the lower border of the liver.
c. Palpate the upper liver border on deep inspiration.
Using deep palpation of a patient's epigastrium, a nurse feels a rhythmic pulsation of the aorta. Based on this finding, what is the nurse's most appropriate response? a. Auscultate this area using the bell of the stethoscope. b. Percuss the area for tones. c. Ask the patient if there is pain in this area. d. Document this as a normal finding.
d. Document this as a normal finding.
When auscultating a patient's abdomen using the bell of the stethoscope, the nurse hears soft, low-pitched murmurs over the right and left upper midline. What do these sounds indicate? a. Expected peristalsis b. Femoral artery stenosis c. Renal artery stenosis d. Hyperactive bowel sounds
c. Renal artery stenosis
To correctly percuss the abdomen, a nurse places the distal aspect of the middle finger of the nondominant hand against the skin of the abdomen, and the other fingers are spread apart and slightly lifted off the skin. How does the nurse use the fingers of the dominant hand? a. The pad of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen. b. The tip of the middle finger strikes the nail of the middle finger touching the skin of the abdomen. c. The tip of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen. d. The pads of the index and middle fingers strike the nail of the middle finger touching the skin of the abdomen.
c. The tip of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen.
A patient reports having frequent heartburn. Which question does the nurse ask in response to this information? a. "Has your abdomen been distended when you feel the heartburn?" b. "What have you eaten in the last 24 hours?" c. "Is there a history of heart disease in your family?" d. "How long after eating do you have heartburn?"
d. "How long after eating do you have heartburn?"
Which technique does the nurse use to palpate a patient's abdomen? a. Asks the patient to breath slowly through the mouth b. Uses the heel of the hand to perform deep palpation c. Uses the left hand to lift the rib cage away from the abdominal organs d. Depresses the abdomen 1 to 2 cm for light palpation
d. Depresses the abdomen 1 to 2 cm for light palpation
