PrepU_Health Assessment_Chapter23

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?" Explanation: Striae are silvery white marks that are common on the abdomen from stretching of the skin during pregnancy or weight gain. They do not cause pain or any other color changes to the skin. High blood pressure may cause the dilation of the superficial arterioles or capillaries with a central star pattern (spider angioma) but would not result in striae

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

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 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?

Correct response: 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.

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?

Correct response: 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.

Where is the linea alba located?

Correct response: Middle of the ventral abdominal wall Explanation: Four layers of large, flat muscles form the ventral abdominal wall and are joined at the midline by a tendinous seam, the linea alba. The lower edge of the costal margin and the anterosuperior iliac spine of the iliac bones are landmarks used to divide the abdomen into regions. The abdomen is a large cavity extending from the xiphoid process of the sternum down to the superior margin of the pubic bone.

Mr. Martin is a 72-year-old smoker who comes to the clinic for a follow-up visit for hypertension. With deep palpation a pulsatile mass about 4 cm in diameter is palpable. What should the examiner do next?

Correct response: Obtain abdominal ultrasound. Explanation: A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 cm. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature.

How should the nurse perform blunt percussion over the liver?

Correct response: Place left hand on right lower rib cage, strike it with ulnar side of right fist Explanation: The correct way of performing blunt percussion is to place left hand on right lower rib cage, strike it with ulnar side of right fist. Placing the hand on the mid of rib cage would not enable the nurse to assess the liver. Placing the right hand on the rib cage and striking with radial side of left hand may not be technically possible.

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

Correct response: costovertebral angle. Explanation: Kidney tenderness is best assessed at the costovertebral angle.

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?

Correct response: visceral Explanation: Visceral pain in the right upper quadrant often suggests liver distension and may be related to alcohol hepatitis. Parietal pain originates from inflammation in the parietal peritoneum also known as peritonitis. Referred pain is felt in the more distant sites, which are innervated at approximately the same spinal levels as the body structure that is inflamed. Right upper quadrant pain is not related to or caused by any problems of the musculoskeletal system.

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

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.

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 Explanation: The spleen resides in the abdominal cavity and stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The pancreas resides in the abdominal cavity and is an endocrine gland producing several important hormones, including insulin. The gallbladder, also located in the abdominal cavity, stores bile before it is released into the small intestine. The liver, an organ also located in the abdominal cavity, has a variety of functions to include detoxification, protein synthesis, and the production of biochemical used in the digestion process.

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 Explanation: Stress incontinence occurs with an increase in intra-abdominal pressure such as when coughing or laughing. Urge incontinence is the inability to hold the urine. Overflow incontinence is the inability to empty the bladder unless the bladder pressure exceeds urethral pressure. Obstructive is not a type of incontinence.

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

Suprapubic Explanation: Bladder disorders may cause suprapubic pain.

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. Explanation: Absent bowel sounds may be associated with peritonitis or paralytic ileus.