PrepU chapter 20

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 regard to this finding?

"Have you been pregnant?"

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

The nurse notes that a client experiencing right lower quadrant abdominal pain when the hip and knee are flexed, and the leg is rotated internally and externally. What should the nurse suspect is occurring with this client?

Appendicitis

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 assess for kidney tenderness at what location?

Costovertebral angle

Older adults often have trouble with swallowing. What might cause this?

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?

The nurse is performing a fluid wave test on a client with suspected ascites. How should the nurse perform this test? Place the following steps into the correct order.

Have the client remain supine. Ask the client to place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen. Firmly place the palmar surface of the nurse's fingers and hand against one side of the client's abdomen. Tap the opposite side of the client's abdominal wall with the other hand

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

Helicobacter pylori

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

The nurse performs the assessment technique shown. What is the nurse assessing in this client?

Liver size

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

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

Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure?

Overflow incontinence

The nurse is teaching a group of new nurses about gastrointestinal changes associated with age. The nurse should provide additional education when a new nurse lists which of the following changes? Select all that apply.

Peristalsis increases with age, Older adults are more sensitive to abdominal pain

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

When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant?

Right kidney, ascending colon, and liver

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 lower quadrant

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?

Right lower quadrant

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located?

Right upper quadrant

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

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.

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem?

Visible peristaltic waves

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

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

right upper

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

right upper quadrant.

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.

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?

Dullness

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 determines that the liver span of an older adult male client measures 6 cm at the MCL. How would the nurse would interpret this finding?

It is a normal-sized liver

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

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

Supine with arms at sides or folded across chest

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

costovertebral angle.

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

identify abdominal organs

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

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

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

paralytic ileus