NUR 346 PrepU: Chapter 23: Assessing Abdomen

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.

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.

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.

When the nurse is obtaining a health history of the urinary system, the client reports "leaking" urine when coughing or laughing. Which of the following problems is the client likely experiencing?

Stress incontinence.

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?

Suprapubic.

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.

A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regards to this finding?

"How many times have you been pregnant?"

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?"

A student nurse is auscultating for bowels sounds on a client who returned from surgery 48 hours ago. The student tells the charge nurse that she cannot hear bowel sounds in the lower quadrants. What is the appropriate response by the charge nurse to this information?

"It takes about 3 to 5 days after surgery for the bowel sounds to return completely."

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

A parietal layer.

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

Abdominal aortic aneurysm.

The nurse suspects an abdominal aortic aneurysm when what is assessed?

Abdominal bruit.

The abdominal contents are enclosed externally by the abdominal wall musculature—three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external

Abdominal oblique.

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.

A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen?

Absent.

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

Appendicitis.

The nurse would assess for positive Blumberg sign how?

Applying and releasing pressure to the abdomen.

A nurse inspects a client's abdomen and notices that a bulge is present in the right lower quadrant. How should the nurse further assess this finding using inspection?

Ask the client to raise the head off the bed.

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

Auscultation.

A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend?

Avoid excessive alcohol intake.

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.

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.

When palpating a client's liver, the nurse feels a firm edge. What would this indicate to the nurse?

Cirrhosis.

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?

Constipation related to decrease in fluid intake.

The nurse assess for kidney tenderness at what location?

Costovertebral angle.

The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the

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.

The pancreas of an adult client is located

Deep in the upper abdomen and is not normally palpable.

The nurse is performing an assessment on a client that is on postop day 2. The abdominal wound has pulled apart and the contents are spilling out. The nurse recognizes this as a what?

Dehiscence.

The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain?

Dyspepsia.

When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?

Family history; dietary habits.

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?

Flex the client's legs by placing a pillow under the knees.

On inspection of abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes this finding is most likely due to what process occurring within the abdominal cavity?

Fluid accumulation.

Which of the following people need to be vaccinated for hepatitis A and B?

Food-service workers.

Nursing students are learning how to identify different areas of the abdomen. What is the lower middle area called?

Hypogastric.

The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation?

Identify abdominal organs.

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

Inflammation of the gallbladder (cholecystitis).

Which is the proper sequence of examination for the abdomen?

Inspection, auscultation, percussion, palpation.

When performing the abdominal assessment for a client, which assessment technique should the nurse perform first?

Inspection.

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.

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible

Internal bleeding.

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?

Irregular, large liver.

A 21-year-old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology?

Irritable bowel syndrome.

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.

A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ?

Kidney.

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

Large intestine.

The sigmoid colon is located in this area of the abdomen: the

Left lower quadrant.

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the

Left upper quadrant.

A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness?

Light palpation.

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?

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?

Listen for a total of 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.

Your patient describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your patient?

Malabsorption syndrome.

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

Masses.

A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement?

Measure abdominal girth.

You are assessing a patient for acute cholecystitis. What sign would you assess for?

Murphy sign.

A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?

Murphy's.

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

Palpate deeply while quickly releasing pressure.

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.

A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment?

Place a small pillow under the client's knees.

How should the nurse perform blunt percussion over the liver?

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

To palpate the spleen of an adult client, the nurse should

Place the right hand below the left costal margin.

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?

Place the tape measure behind the client and measure at the umbilicus.

The nurse assesses a client's indwelling urinary catheter bag and observes cloudy urine. The client also complains of lower back pain. What is the nurse's best action?

Prepare to obtain a urine specimen for culture.

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.

To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's

Right lower quadrant.

The nurse correctly identifies the gallbladder is located where?

Right upper quadrant.

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's

Right upper quadrant.

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

Right upper.

Which nursing diagnosis is most appropriate for an elderly client with poor dentition?

Risk for Imbalanced Nutrition: Less Than Body Requirements.

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?

The presence of normal tympany over this area.

A student is performing a physical assessment on a client. While assessing the abdomen, the student percusses the spleen. What sound would be normal for the student to hear?

Tympany.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible

Umbilical hernia.

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should

Use the diaphragm of the stethoscope.

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.

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.