Health Assessment Exam 5 part 2

A nurse observes 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? "How many times have you been pregnant?" "Are you experiencing any abdominal pain?' "Have you noticed any color change to the skin?' "Do you have high blood pressure?"

"How many times have you been pregnant?"

The nurse is beginning the inspection of a young adult client's breasts. The client states, "My left breast has always been a bit bigger than the right." How should the nurse best respond to the client's statement? "Many women have this, and it's rarely a sign of a health problem." "That's very normal, and it usually resolves over time as you get older." "If you lose some weight, the size disparity will likely decrease." "I'll make sure to refer to the doctor to get this assessed further."

"Many women have this, and it's rarely a sign of a health problem."

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what? Abdominal aortic aneurysm Abdominal tumor Acites Inflammation

Abdominal aortic aneurysm

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon? Absorbing electrolytes Secreting digestive enzymes Absorbing large amounts of water Secreting bile

Absorbing large amounts of water

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen? Accentuated tympany Hyperresonance Tympany Dullness

Accentuated tympany

The nurse reviews factors related to which of the following areas to assess a client's risk of breast cancer? Family history, age, occupation Age, family history, reproductive history Lifestyle, occupation, exposure to hazardous chemicals Exposure to hazardous chemicals, lifestyle, reproductive history

Age, family history, reproductive history

During a prenatal breastfeeding class, a participant says her breasts are not large enough to breastfeed. When responding to this client, the nurse would incorporate understanding that the functional capacity of the breast is determined by which of the following? Amount of glandular tissue Breast size Amount of fatty tissue Subcutaneous fat layer

Amount of glandular tissue

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? Peptic ulcer Cholecystitis Pancreatitis Appendicitis

Appendicitis

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

Appendicitis

The nurse instructs a female client on breast self-examination. Which part of the breast should the nurse explain as being the area where most cancers occur? Upper inner Upper outer Lower inner Lower outer

Upper Outer

Linda is a 29-year-old who had excruciating pain that started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely given this presentation? Appendicitis Dysmenorrhea Ureteral stone Ovarian cyst

Ureteral stone

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem? Abdominal respiratory movements Visible peristaltic waves Symmetric appearance No bulging with head raising

Visible peristaltic waves

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

right upper quadrant.

Mrs. Ash, a client in her 50s, has told the nurse during her most recent visit to the clinic that she and her circle of friends have discontinued breast self-examination (BSE) since hearing and reading that the practice is now considered ineffective. How can the nurse best respond to Mrs. Ash? "Actually, the recent statistics show that BSE plays a key role in reducing a woman's risks of death from breast cancer." "It's true that BSE doesn't really help to detect cancerous masses, but it's still a good way to be systematic about assessing your own health." "BSE is certainly not a replacement for other screening methods, but a high proportion of breast masses are in fact detected by women themselves." "As long as you are conscientious about getting mammograms and clinical examinations regularly, there is likely no need for you to continue doing BSE."

"BSE is certainly not a replacement for other screening methods, but a high proportion of breast masses are in fact detected by women themselves."

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? "I'm going to examine the area where you're having pain first to get a better picture of what's going on." "Before I get ready to examine the painful area, I will let you know in plenty of time." "You don't need to worry about anything. I will make sure to be very gentle during the exam." "Since you're having pain in a certain area, I won't have to do a very thorough exam there."

"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 or does anyone in your immediate family have a history of colon cancer?" "Do you experience any heartburn or regurgitation of food after a meal?" "Do you find that any particular foods, like dairy, make the problem worse?" "Have you experienced any significant change in your weight in recent months, either up or down?"

"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? Antibodies A parietal layer A visceral ligament A drying agent

A parietal layer

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

Applying and releasing pressure to the abdomen

A client has presented for care to the clinic, stating, "I'm pretty sure that I feel a new lump in my breast." After confirming the presence of a lump, what action should the nurse take next? Arrange for the client to be brought to the hospital emergency department immediately. Tell the client to monitor the lump for the next three weeks and seek care if it increases in size. Arrange for a prompt referral to her primary care provider. Facilitate a referral to an oncologist if more lumps emerge in the coming weeks.

Arrange for a prompt referral to her primary care provider.

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 eating overcooked foods Avoid excessive alcohol intake Avoid taking pain medications with food Avoid taking antacid medications

Avoid excessive alcohol intake

Jim is a 60-year-old man who presents with vomiting. He denies any blood in his emesis, which has been present for 2 days. He does note a dark granular substance resembling the coffee left in the filter after brewing. What should the nurse suspect? Bleeding from a diverticulum Bleeding from a peptic ulcer Bleeding from colon cancer Bleeding from cholecystitisv

Bleeding from a peptic ulcer

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? Absent Hypoactive Borborygmus Erratic

Borborygmus

When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding? Bowel sounds normal Bowel sounds hyperactive Bowel sounds hypoactive Bowel sounds inconsisten

Bowel sounds normal

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

Bruit

Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect? Ascites Appendicitis Cholecystitis Splenomegaly

Cholecystitis

The nurse assess for kidney tenderness at what location? Costovertebral angle Midclavicular line Hypogastric area Umbilical region

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 Gastric ulcer Pancreatitis Gastroesophageal reflux

Crohn's disease

Why is the appearance of urine important to evaluate during an abdominal examination? Dark urine may be from dehydration Cloudy urine rules out urinary tract infection Blood could indicate cholecystitis Sediment in the urine could indicate malnutrition

Dark urine may be from dehydration

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? Inadequate hydration Poor nutrition Higher fat-to-lean muscle ratio Decreased activity of protective bacteria in the urinary tract

Decreased activity of protective bacteria in the urinary tract

Older adults often have trouble with swallowing. What might cause this? Slowing of peristalsis Decreased saliva production Decreased stomach acid Constipation

Decreased saliva production

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? Do you have heartburn, indigestion, anorexia, or unplanned weight loss? Is there any family history of gastric cancer? Is there any personal or family history of ulcerative colitis or Crohn's disease?

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

During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate? Refer the client for medical follow-up. Evaluate further for a problem with the spleen. Assess urinary output. Document the position of the liver.

Document the position of the liver.

Which factors should the nurse include in a discussion with a young female to assist the client to reduce her risk for breast cancer? Select all that apply. Engage in regular, strenuous physical activity Increase the intake of fat in the diet Pregnancy is beneficial before 30 years of age Breast-feed if possible Regular intake of alcohol, two to three drinks daily

Engage in regular, strenuous physical activity Pregnancy is beneficial before 30 years of age Breast-feed if possible

The nurse notes that a client's abdominal skin is pale and taut. What should the nurse suspect is causing this finding? Inflammation of the liver Bleeding within the abdominal wall Obstruction of the inferior vena cava Fluid accumulating in the abdominal cavity

Fluid accumulating in the abdominal cavity

While examining a client's breasts, a nurse notices milky discharge from the nipple. The client explains that she recently had a baby and is currently breastfeeding. The nurse understands that which type of tissue in the breast is responsible for allowing milk production? Fibrous Fatty Glandular Lymphatic

Glandular

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 C Hepatitis B and C Hepatitis A and B Hepatitis A

Hepatitis A and B

- While interviewing a client, the nurse asks her what her typical daily diet consists of. Which of the following is associated with an increased risk for breast cancer? A glass of wine daily Two cups of coffee per day High-sugar diet High-fat diet

High-fat diet

While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating what complication? Hernia Malignancy Infection Aneurysm

Infection

The nurse as elicited a positive Murphy sign. The knows this is indicates what? Inflammation of the gallbladder Appendicitis Kidney pain Peritonitis

Inflammation of the gallbladder

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

Internal adhesions from previous surgery

A 77-year-old retired bus driver presents at his wife's request to the clinic for a physical examination. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for more than 40 years. He denies any tobacco or drug use and has not drunk alcohol since getting married. His parents both died of cancer in their 60s. On examination his vital signs are in expected ranges. His head, cardiac, and pulmonary examinations are unremarkable. Abdominal examination reveals normal bowel sounds. Results of palpation of the liver are abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination? Smooth, large, nontender liver Irregular, large liver Smooth, large, tender liver

Irregular, large liver

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? Colon cancer Cholecystitis Inflammatory bowel disease Irritable bowel syndrome

Irritable bowel syndrome

A nurse determines that the liver span of an older adult male client measures 6 cm. How would the nurse would interpret this finding? It is a normal-sized liver. The liver is larger than normal. The liver is smaller than normal. The liver has atrophied.

It is a normal-sized liver.

Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound? It is a splenic rub. It is a variant of bowel noise. It represents borborymi. It is a vascular noise.

It is a splenic rub.

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? Peritoneum Linea alba Internal abdominal oblique Transverse abdominis

Linea alba

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? Document the absence of bowel sounds Assess for findings of dehydration Listen for a total of five (5) minutes Palpate for abdominal rigidity

Listen for a total of five (5) minutes

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 Pancreas Gallbladder Kidneys

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? GI bleed Dehydration Liver disease Gastroenteritis

Liver disease

A 43-year-old store clerk comes to the office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago); until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The client does not smoke, drink, or use illegal drugs. Her father is in good health. Examination shows a tense woman appearing her stated age. Visual inspection of her left axilla reveals a tense red area with no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examination of the left arm reveals a scabbed-over superficial laceration over her left hand. Upon questioning, the client remembers that she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms? Breast cancer Lymphadenopathy of infectious origin Hidradenitis suppurativa

Lymphadenopathy of infectious origin

When palpating a female client's axillae, which finding would the nurse document as normal? Node size is 1.2 cm. Nodes are fixed. Nodes are hard. Nodes are discrete.

Nodes are discrete.

The nurse is assessing an adult client with right lower quadrant abdominal pain. The client has no history of prior surgeries, has no allergies, and is physically fit. Which of the following should the nurse do during the abdominal examination? Observe the client's face for signs of discomfort Examine the abdomen with the client's bladder full Place the client supine with arms extended up Do not distract the client with questions while performing the examination

Observe the client's face for signs of discomfort

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? Obturator Psoas Murphy's Rovsing's

Obturator

Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure? Urge incontinence Functional incontinence Stress incontinence Overflow incontinence

Overflow incontinence

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? Palpate the right lower quadrant for rebound tenderness. Test for a fluid wave. Assess for Murphy's sign. Assess for the obturator sign.

Palpate the right lower quadrant for rebound tenderness.

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? Hold the nurse's hands under warm water just before the examination Drape the client's genital area when the client is not being examined Adjust the bed level Place the client's hand under the nurse's hand for a few moments

Place the client's hand under the nurse's hand for a few moments

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? Positive Rovsing's sign Psoas sign present Obturator sign positive Positive skin hypersensitivity test

Positive Rovsing's sign

Which of the following is consistent with obturator sign? Pain distant from site used to check rebound tenderness Right hypogastric pain with the right hip and knee flexed, and the hip internally rotated Pain with extension of the right thigh while the client is on the left side or while pressing the knee against the examiner's hand with thigh flexion Pain in the right upper quadrant that stops inhalation

Right hypogastric pain with the right hip and knee flexed, and the hip internally rotated

Rovsing's sign is a test of referred rebound tenderness in appendicitis. True False

True

The nurse correctly identifies the gallbladder is located where? RUQ RLQ LUQ LLQ

RUQ

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 Radiated pain Localized pain Chronic pain

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.

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? Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant

Right lower quadrant

A nurse is preparing to palpate a client's spleen. Which position should the nurse use to bestfacilitate palpation? Sitting upright Prone Semi-Fowler's Right side-lying

Right side-lying

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? Gallbladder Liver Spleen Head of pancreas

Spleen

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

Spleen

A client is experiencing parietal abdominal pain. The nurse would expect the client to describe the pain as which type of sensation? Dull Steady Cramping Burning

Steady

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? Refer the client to an oncologist. Provide a dietician consult for the client. Counsel the client regarding hernia repair. Stop palpating and get medical assistance.

Stop palpating and get medical assistance.

When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach. True False

True

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

Suprapubic

The nurse is preparing to palpate the client's spleen. What should the nurse instruct the client to do? Take a deep breath and hold it Take a deep breath and exhale Have the client lie on his left side Have the client lie on his right side

Take a deep breath and exhale

The nurse is assessing the gastrointestinal system of an 81-year-old client. What age-related change should the nurse consider when collecting and analyzing assessment data? The client is more vulnerable to impaired nutrition due to decreased appetite. The client derives less nutritional value from food because of decreased enzyme production. The client's liver will be significantly larger than that of a younger client. The client will have greater bowel motility than a younger adult.

The client is more vulnerable to impaired nutrition due to decreased appetite.

An 18-year-old woman complains because one breast is larger than the other. What additional interview data would suggest a need for referral? The client states that she is sexually active. The client states that she does not perform breast self-examination. The client states that her problem affects her body image. The client states that this represents a sudden change in her breast size.

The client states that this represents a sudden change in her breast size.

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

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 three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history? This area should be avoided completely The left lower quadrant is palpated last Medicate for pain before beginning the assessment Encourage the client to relax to minimize pain

The left lower quadrant is palpated last

A young client presents with a left-sided mass in her abdomen. It is present in the left upper quadrant. Which of the following would support that this represents an enlarged kidney rather than her spleen? A palpable "notch" along its edge The inability to push fingers between the mass and the costal margin The presence of normal tympany over this area The ability to push fingers medial and deep to the mass

The presence of normal tympany over this area

While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen? To identify the edges of abdominal organs To identify abdominal tenderness To identify the distribution of gas in the abdomen To identify bowel sounds

To identify bowel sounds

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

auscultation

A nurse suspects that a client has gastroesophygeal reflux disease (GERD). Which risk factors must be present for the nurse to confirm this? Select all that apply. body mass index greater than 30 taking multiple medications alcohol consumption hiatal hernia passing excess flatus

body mass index greater than 30 taking multiple medications hiatal hernia

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? constipation sigmoid colon lesion clostridium difficile infection pancreatic insufficiency

constipation

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

costovertebral angle.

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? Acute diverticulitis Acute cholecystitis Acute appendicitis Mesenteric ischemia

diverticulitis

The size and shape of the breasts in females are related to the amount of glandular tissue. fibrous tissue. lactiferous ducts. fatty tissue.

fatty tissue.

Which characteristic would support the determination that a client is at high risk for breast cancer? history of lobular hyperplasia first degree relative with a history of either BRCA1 or BRCA2 mutation extremely dense breast tissue history of atypical ductal hyperplasia

first degree relative with a history of either BRCA1 or BRCA2 mutation

The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation? identify abdominal organs discern muscular resistance detect abdominal tenderness complete a surface evaluation

identify abdominal organs

The lymph nodes that are responsible for drainage from the arms are the central lymph nodes. anterior lymph nodes. lateral lymph nodes. posterior lymph nodes.

lateral lymph nodes.

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

left upper quadrant.

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 gallbladder disease. cachexia. kidney trauma. masses.

masses

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 aortic aneurysm. paralytic ileus. gastroenteritis. fluid and electrolyte imbalances.

paralytic ileus.

To palpate the spleen of an adult client, the nurse should ask the client to exhale deeply. place the right hand below the left costal margin. point the fingers of the left hand downward. ask the client to remain in a supine position.

place the right hand below the left costal margin.

What instruction should the nurse provide to a client to assess for dimpling or retraction of breast tissue? shrug the shoulders raise arms over the head bend both arms at the elbows extend the arms out to the side

raise arms over the head

The colon originates in this abdominal area: the right lower quadrant. right upper quadrant. left lower quadrant. left upper quadrant.

right lower quadrant.

A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of stomach ulcers. pancreatic cancer. decreased gastric motility. abdominal tumors.

stomach ulcers.

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

use the diaphragm of the stethoscope.

Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is usually difficult to localize right or left sided more severe than parietal pain also called referred pain

usually difficult to localize

A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition? viral hepatitis toxic liver damage alcohol hepatitis intrahepatic jaundice

viral hepatitis

A nurse is assessing a client with a history of alcohol abuse. The client reports right upper quadrant pain. Which type of pain is the client experiencing? visceral parietal referred musculoskeletal

visceral