Health Assessment Chapter 20: Abdominal Assessment
The client would complain of pain in what quadrant if experiencing appendicitis? A) RUQ B) RLQ C) LUQ D) LLQ
B) RLQ Explanation: With appendicitis, the client would experience pain in the RLQ.
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. Explanation: 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.
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. Explanation: The spleen is located in the left upper quadrant.
A 23-year-old man has recently graduated from university and is preparing to embark on a backpacking trip around Southeast Asia. In preparation for his trip, the client has visited a clinic to obtain vaccinations. The client will be able to obtain vaccines protecting against which of the following? A) Hepatitis C B) Hepatitis B and C C) Hepatitis A and B D) Hepatitis A
C) Hepatitis A and B Explanation: Vaccines are available for hepatitis A and B.
The nurse notes that a client's abdominal skin is pale and taut. What should the nurse suspect is causing this finding? A) Inflammation of the liver B) Bleeding within the abdominal wall C) Obstruction of the inferior vena cava D) Fluid accumulating in the abdominal cavity
D) Fluid accumulating in the abdominal cavity Explanation: Pale taut skin may be seen with ascites which is significant abdominal swelling that indicates fluid accumulation in the abdominal cavity. Jaundice would be present if the liver is inflamed. Purple discoloration at the flank areas indicates bleeding within the abdominal wall. Dilated veins may be seen with obstruction of the inferior vena cava.
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what? A) Abdominal aortic aneurysm B) Abdominal tumor C) Ascites D) Inflammation
A) Abdominal aortic aneurysm Explanation: Pulsation of the aorta may be increased and lateralized in an abdominal aortic aneurysm. Ascites is collection of fluid in the abdomen. Inflammation and tumors do not pulsate.
A 26-year-old sports store manager comes to the clinic with severe right-sided abdominal pain for 12 hours. He began having a stomach ache yesterday with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 38.8° and his heart rate is 170. His bowel sounds are decreased, and he has rebound and involuntary guarding at one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain? A) Acute appendicitis B) Acute mechanical intestinal obstruction C) Acute cholecystitis D) Mesenteric ischemia
A) Acute appendicitis Explanation: Appendicitis is common in the young and usually presents with periumbilical pain that localizes to the right lower quadrant in an area known as McBurney's point, described as one third of the way between the anterior superior iliac spine and the umbilicus on the right. Rebound and guarding are common. Remote rebound or Rovsing's sign is also seen commonly when the course of appendicitis is advanced. Bowel movements are usually unaffected.
A 76-year-old retired farmer comes to the office reporting abdominal pain, constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or diarrhea. The only unusual thing he remembers eating was two bags of popcorn at the movies with his grandson 3 days before his symptoms began. He denies any other recent illnesses. His past medical history is significant for coronary artery disease and high blood pressure. He has been married for more than 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon cancer and his father had a stroke. On examination he appears his stated age and is in no acute distress. His temperature is 100.9 degrees; other vital signs are unremarkable. His head, cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable, and his fecal occult blood test is negative. His prostate is slightly enlarged, but his testicular, penile, and inguinal examinations are all normal. Blood work is pending. What diagnosis for abdominal pain best describes his symptoms and signs? A) Acute diverticulitis B) cute cholecystitis C) Acute appendicitis D) Mesenteric ischemia
A) Acute diverticulitis Explanation: Diverticulitis is caused by localized infections within the colonic diverticula. Constipation, fever, and abdominal pain are common. Mesenteric ischemia classically presents in older people with a history of vascular disease elsewhere. The typical pain is unusual in that it is not made worse by examination despite being severe. Some mistake this feature to indicate malingering with bad results.
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 Explanation: 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.
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 Explanation: Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.
Which additional health history question related to the abdominal system is appropriate for people of African American decent? A) Do you or your parents have sickle cell disease or trait? B) Do you have heartburn, indigestion, anorexia, or unplanned weight loss? C) Is there any family history of gastric cancer? D) Is there any personal or family history of ulcerative colitis or Crohn's disease?
A) Do you or your parents have sickle cell disease or trait? Explanation: Sickle cell anemia has an autosomal recessive inheritance pattern and is most common among African Americans. Incidence of gastric and primary liver cancers is increased in Asians. Inflammatory bowel diseases and symptoms of heartburn, indigestion, anorexia, or unplanned weight loss are appropriate questions for clients of all ethnicities.
The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant? A) Dullness B) Hollow tympanic notes C) Rub D) Hum
A) Dullness Explanation: Normal percussion findings include dullness over the liver in the RUQ and hollow tympanic notes in the LUQ over the gastric bubble. Hums and rubs are auscultatory sounds.
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize? A) Family history; dietary habits B) Dietary habits; social patterns C) Surgical history; family history D) Social patterns; past medical history
A) Family history; dietary habits Explanation: Poor diet and a family history are both identified as risk factors for colorectal cancer. These aspects of the history would supersede the client's surgical history and social patterns.
Which of the following people need to be vaccinated for hepatitis A and B? A) Food-service workers B) Office personnel C) Truck drivers D) Animal care workers
A) Food-service workers Explanation: Hepatitis A and B immunizations are recommended for all infants; people whose work may expose them to blood, body fluids, or unsanitary conditions (i.e., health care, food services, sex workers); and those traveling to parts of the world where these illnesses are prevalent.
A client presents to the emergency department with reports of new onset of abdominal pain for the past three (3) days. The client states there is also a pulling feeling on the right side. Upon examination the nurse notices a 5cm 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 Explanation: The key to this question is the presence of the scar. The scar in the right lower quadrant should alert the nurse to the possibility of internal adhesions which account for the pulling feeling the client reports. 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.
The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant with right flank pain. Which assessment should the nurse conduct next? A) Palpate the right lower quadrant for rebound tenderness. B) Test for a fluid wave. C) Assess for Murphy's sign. D) Assess for the obturator sign.
A) Palpate the right lower quadrant for rebound tenderness. Explanation: Localized tenderness anywhere in the right lower quadrant, even in the right flank, suggests appendicitis. The nurse should follow this finding with an assessment of rebound tenderness. This will assist the nurse in determining if the client is guarding and develops muscle rigidity-two additional features of appendicitis. The test for fluid wave is used to identify ascites in the client. The manner in which the client presented does not warrant an assessment for ascites. Murphy's sign is used to assess for acute cholecystitis. A positive obturator sign can suggest inflammation of the appendix; however, this test has low sensitivity. For this reason, rebound tenderness should be assessed first.
A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding? A) Positive Rovsing's sign B) Psoas sign present C) Obturator sign positive D) Positive skin hypersensitivity test
A) Positive Rovsing's sign Explanation: Findings indicating referred rebound tenderness constitute a positive Rovsing's sign. Psoas sign occurs when pain in the right lower quadrant occurs with raising of the client's right leg from the hip and pressure applied downward against the lower thigh. The obturator sign occurs when pain in the right lower quadrant results when the client's right knee and ankle are supported and the leg is rotated internally and externally. A positive hypersensitivity test occurs when the client experiences pain or exaggerated sensation when the abdomen is stroked with a sharp object.
A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse interprets this as which of the following? A) Positive Rovsing's sign B) Psoas sign C) Obturator sign D) Positive skin hypersensitivity test
A) Positive Rovsing's sign Explanation: Findings indicating referred rebound tenderness is a positive Rovsing's sign. Psoas sign occurs when pain in the right lower quadrant occurs with raising of the client's right leg from the hip and pressure applied downward against the lower thigh. The obturator sign occurs when pain in the right lower quadrant results when the client's right knee and ankle are supported and the leg is rotated internally and externally. A positive hypersensitivity test occurs when the client experiences pain or exaggerated sensation when the abdomen is stroked with a sharp object.
An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide? A) Quit smoking as soon as possible. B) Exercise for at least 30 minutes, three times per week. C) Eat several small meals a day rather than three larger meals. D) Attend screening clinics at least twice per year.
A) Quit smoking as soon as possible. Explanation: Smoking cessation reduces the risk of PUD. Multiple small meals are not a preventative measure, and there are no current screening recommendations. Exercise has multiple health benefits, but prevention of PUD is not among them.
The nurse correctly identifies the gallbladder is located where? A) RUQ B) RLQ C) LUQ D) LLQ
A) RUQ Explanation: The gallbladder is located in the right upper quadrant of the abdomen.
When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant? A) Right kidney, ascending colon, and liver B) Right ovary, pancreas, and sigmoid colon C) Right ovary, descending colon, and spleen D) Right kidney, transverse colon, and inguinal ligament
A) Right kidney, ascending colon, and liver Explanation: The pole of the right kidney, the ascending colon, and the liver are all present in the RUQ. The pancreas, descending colon, sigmoid colon, spleen, and inguinal ligament are not.
Which nursing diagnosis is most appropriate for an elderly client with poor dentition? A) Risk for Imbalanced Nutrition: Less Than Body Requirements B) Constipation C) Fluid volume deficit D) Diarrhea
A) Risk for Imbalanced Nutrition: Less Than Body Requirements Explanation: A client with poor dentition is at risk for Imbalanced Nutrition: Less Than Body Requirements as teeth may be missing or chewing may be difficult. None of the other diagnosis are related to poor dentition.
A mother is worried about her teenage child's weight. The teenager weighs 80 kg (176 lbs). What can the nurse teach the mother about her child's eating habits? Select all that apply. A) Supply only healthy foods in the house B) Supply nutritional information to the child C) Educate the family about the poor nutritional value of fast food D) Tell the mother that a teenager requires 3,500 calories per day E) Teach the mother that teenagers rarely have diet-related problems such as iron deficiency and anemia
A) Supply only healthy foods in the house B) Supply nutritional information to the child C) Educate the family about the poor nutritional value of fast food Explanation: Teenagers assume control of their eating and may reject family values. The only control parents may have is over what food is in the house, although they should still supply nutritional information to their children. Fast food is high in fat, calories, and salt and has little fiber. Moderately active teenage girls require an average of 2,200 calories per day. Moderately active teenage boys require an average of 2,800 calories a day
The nurse is taking the health history of a client who takes a calcium channel blocking medication for hypertension. The client reports a sensation of incomplete evacuation when having a bowel movement about three times per week. For which problem should the nurse further assess the client? A) constipation B) sigmoid colon lesion C) clostridium difficile infection D) pancreatic insufficiency
A) constipation Explanation: Clients with constipation have 25% or more defecations with either straining or a sensation of incomplete evacuation per week. Sigmoid colon lesions are characterized by thin, pencil-like stools due to an obstructing "apple-core" lesion in this area of the bowel. A clostridium difficile infection is characterized by diarrhea and should be suspected if the client has recently been hospitalized. Pancreatic insufficiency should be further investigated if the client reports having oily or greasy stools.
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 Explanation: 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.
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 Explanation: 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. Explanation: 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 exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem? A) "Do you feel like you're able to adequately address the stress in your life?" B) "Do you take painkillers like aspirin on a regular basis?" C) "Do you tend to eat foods that are quite high in fat?" D) "Are you currently taking vitamin supplements?"
B) "Do you take painkillers like aspirin on a regular basis?" Explanation: Regular use of nonsteroidal anti-inflammatory medications (NSAIDs) is implicated in the incidence of PUD. Stress is a contributing, but not causative, factor. Vitamin supplements and a high-fat diet are not considered to be causative factors.
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 Explanation: 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.
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 Explanation: 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 no bowel movement for four (4) days, bloating, and generalized abdominal discomfort. She states she has not been eating and drinking correctly and is stressed because she has a final exam in two (2) days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants, tenderness in the left lower quadrant with a few small round, firm masses. Rovsing's sign and the 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 Explanation: The nurse can confirm constipation because the major defining characteristics of decreased frequency and abdominal discomfort are present. A few days of altered nutrition does not meet the necessary criteria to confirm Ineffective Nutrition or risk for Fluid Volume Deficit. Ineffective Health Maintenance cannot be confirmed because there is no evidence that the client lacks the knowledge to eat properly.
A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor? A) Excessive fat and sugar intake B) Overuse of laxatives C) Obesity D) Inadequate abdominal muscle tone
B) Overuse of laxatives Explanation: Overuse of laxatives may decrease intestinal tone and promote dependency, contributing to chronic constipation. Constipation is not attributable to low abdominal muscle tone. Obesity and excessive sugar and fat intake may exacerbate constipation but will not independently cause the health problem.
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 Explanation: 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.
A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem? A) Abdominal respiratory movements B) Visible peristaltic waves C) Symmetric appearance D) No bulging with head raising
B) Visible peristaltic waves Explanation: Visible peristaltic waves typically are not visible except in very thin people. An increase in peristaltic waves with progression in a ripple like fashion suggests intestinal obstruction, necessitating further evaluation. Abdominal respiratory movements are normal findings in a male client. Symmetric appearance and absence of bulging when the client raises his head are also normal findings.
Which is the proper sequence of examination for the abdomen? A) Auscultation, inspection, palpation, percussion B) Inspection, percussion, palpation, auscultation C) Inspection, auscultation, percussion, palpation D) Auscultation, percussion, inspection, palpation
C) Inspection, auscultation, percussion, palpation Explanation: The abdominal examination is conducted in a sequence different from other systems. Usually the order is inspection, percussion, palpation, then auscultation. Because palpation may actually cause some bowel noise when the bowels are not moving, auscultation is performed before percussion and palpation.
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 Explanation: Bowel sounds normally occur every 5 to 15 seconds. In a client with nausea and vomiting, bowel sounds may be hypoactive. The nurse should listen for a total of 5 minutes to confirm the absence of bowel sounds. 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 auscultates for bowels sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after one 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 five (5) minutes D) Palpate for abdominal rigidity
C) Listen for a total of five (5) minutes Explanation: Bowel sounds normally occur every 5 to 15 seconds. In a client with nausea and vomiting, bowel sounds may be hypoactive. The nurse should listen for a total of 5 minutes to confirm the absence of bowel sounds. 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.
To promote relaxation of the client's abdominal muscles, what would be most appropriate for the nurse to do? A) Encourage the client to hold his or her breath. B) Cover the client in a warm blanket. C) Place a pillow under both of the client's knees. D) Assure the client that painful areas will not be examined.
C) Place a pillow under both of the client's knees. Explanation: Placing a pillow under the client's knees provides slight flexion, which helps to relax the abdominal muscles. Having the client breathe through the mouth and take slow deep breaths promotes overall relaxation. A warm blanket prevents chilling. The nurse would inform the client that painful areas will be assessed last and would assure the client that he or she will be forewarned about examining these areas.
The nurse is evaluating a new graduate's ability to perform a rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location? A) Right upper quadrant B) Left upper quadrant C) Right lower quadrant D) Left lower quadrant
C) Right lower quadrant Explanation: The appendix is located in the right lower quadrant. If the client has appendicitis, pressing deeply in this location with a sudden release of pressure will elicit a sharp, stabbing pain, which is called "rebound tenderness."
The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location? A) Right upper quadrant B) Left upper quadrant C) Right lower quadrant D) Left lower quadrant
C) Right lower quadrant Explanation: The appendix is located in the right lower quadrant. If the client has appendicitis, pressing deeply in this location with a sudden release of pressure will elicit a sharp, stabbing pain, which is called "rebound tenderness."
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. Explanation: 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.
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 Explanation: 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.
Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure? A) Urge incontinence B) Functional incontinence C) Stress incontinence D) Overflow incontinence
D) Overflow incontinence Explanation: Stress incontinence with increased intra-abdominal pressure suggests decreased contractility of the urethral sphincter or poor support of bladder neck; urge incontinence, if unable to hold the urine, suggests detrusor overactivity; overflow incontinence, when the bladder cannot be emptied until bladder pressure exceeds urethral pressure, indicates anatomic obstruction by prostatic hypertrophy or stricture, or neurogenic abnormalities.
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? A) Hold the nurse's hands under warm water just before the examination B) Drape the client's genital area when the client is not being examined C) Adjust the bed level D) Place the client's hand under the nurse's hand for a few moments
D) Place the client's hand under the nurse's hand for a few moments Explanation: 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.
During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take? A) Refer the client to an oncologist. B) Provide a dietician consult for the client. C) Counsel the client regarding hernia repair. D) Stop palpating and get medical assistance.
D) Stop palpating and get medical assistance. Explanation: If the nurse palpates a prominent pulsating mass, the suspicion is high for an abdominal aortic aneurysm. The nurse should stop palpating immediately and seek medical assistance because the risk of rupture is great. The mass does not suggest a malignancy or hernia, nor does it indicate a need for a dietary consult.
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 Explanation: A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenburg, or semi-Fowler's position.
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. Explanation: A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue.
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should A) perform this abdominal assessment first. B) ask the client to assume a side-lying position. C) palpate lightly while slowly releasing pressure. D) palpate deeply while quickly releasing pressure.
D) palpate deeply while quickly releasing pressure. Explanation: If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen away from the painful or tender area. Then suddenly release pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred.
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. Explanation: The appendix is located in the right lower quadrant.
