Health Assessment Chapter 20 PrepU

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?

Absent

Your patient has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for?

Acute pancreatitis

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?

Appendicitis

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what?

Appendicitis

A 27-year-old policewoman comes to the clinic with severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate, but she has no burning on the outside. She has had no frequency or urgency with urination, but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative, and her urine analysis shows red blood cells. What type of urinary tract pain is she most likely to have?

Ureteral pain (from a kidney stone)

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

paralytic ileus.

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?

Abdominal aortic aneurysm

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?

"Before I get ready to examine the painful area, I will let you know in plenty of time."

A 49-year-old woman has visited the clinic with complaints of excessive flatus and bloating, symptoms that are causing her both discomfort and embarrassment. Which of the following questions should the nurse ask the client during assessment of the health problem?

"Do you find that any particular foods, like dairy, make the problem worse?"

The peritoneum is a serous membrane that contains which of the following?

A parietal layer

A 66-year-old client has presented to the clinic complaining of recurrent constipation and the passage of thin, pencil-like stools. What diagnostic test should the nurse prioritize?

Fecal occult blood test (FOBT)

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?

Borborygmus

The nurse auscultates 20 clicks and gurgles over 1 minute when examining a patient's abdomen. How should the nurse document this finding?

Bowel sounds normal

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.

• Weight • Food intake

The nurse assess for kidney tenderness at what location?

Costovertebral angle

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?

Crohn's disease

Why is the appearance of urine important to evaluate during an abdominal examination?

Dark urine may be from dehydration

The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location?

Deep epigastrium to the left of midline

Which additional health history question related to the abdominal system is appropriate for people of African American decent?

Do you or your parents have sickle cell disease or trait?

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved?

Gallbladder

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

Gastric ulcer

A daycare worker presents to the office with jaundice. She denies IV drug use, blood transfusion, and travel, and has not been sexually active for the past 10 months. Which type of hepatitis is most likely?

Hepatitis A

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?

Hepatitis A and B

The nurse as elicited a positive Murphy sign. The knows this is indicates what?

Inflammation of the gallbladder

A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Inspect, auscultate, percuss, palpate

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?

Irritable bowel syndrome

Nursing students are giving a class presentation on the digestive process. The students would identify villi as being present in what part of the GI tract?

Jejunum

Where in the digestive tract is most of the water absorbed?

Large intestine

The nurse is palpating in the right upper abdominal quadrant and feels and enlarged area. The nurse recognizes that she is most likely feeling what organ?

Liver

A patient's most recent laboratory results indicate increases in alanine aminotransferase (ALT) and aspartate aminotransferase (AST). What might the nurse suspect is wrong with this patient?

Liver disease

The nurse assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C (99.3°F;). Which of the following interventions is appropriate for this client?

Monitor pulse and blood pressure every 15 minutes until stable

To promote relaxation of the client's abdominal muscles, which of the following would be most appropriate for the nurse to do?

Place a pillow under both of the client's knees.

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 should document which of the following?

Positive Rovsing's sign

The nurse understands that the liver does what?

Produces clotting factors

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?

Referred pain

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

Right lower quadrant

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant?

Spleen

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?

Spleen

The nurse understands this abdominal organ is responsible for storing red blood cells and platelets.

Spleen

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?

Spleen

Which of the following should a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?

Splenomegaly

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?

Stop palpating and get medical assistance.

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus?

Stop palpating and get medical assistance.

When inspecting the abdomen, which of the following client positions facilitates correct examination technique?

Supine with arms at sides or folded across chest

Your patient has a bladder disorder. Where would you expect the pain to be?

Suprapubic

The student nurse is assessing a geriatric client's risk for nutritional deficits. Which of the following would the student nurse consider as risk factors?

The client is a widower.

Which of the following statements provides the most accurate guide to the assessment of the gallbladder?

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.

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?

The left lower quadrant is palpated last

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

appetite changes.

The nurse is interviewing a client who has some common abdominal symptoms. Which one of the following symptoms is commonly associated with the abdominal assessment?

dysphagia

While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tingling sounds throughout the distended abdomen. The nurse should refer the client to a physician for possible

intestinal obstruction.

The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should

palpate deeply while quickly releasing pressure.

To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should

raise the client's right leg from the hip.

The colon originates in this abdominal area: the

right lower quadrant.

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant?

right upper

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.

• Supply only healthy foods in the house • Supply nutritional information to the child • Educate the family about the poor nutritional value of fast food

The nurse notes guarding while palpating the abdomen of a newly admitted patient despite asking the patient to try to relax. The nurse should (Select all that apply.)

• distract the patient with conversation • have the patient mouth breathe with the jaw dropped open • assess relaxation of abdominal muscle after the patient exhales