Abdomen

A nurse is preparing to perform light palpation of a client's abdomen. In which order should the nurse perform the following steps?

1. Place the client's arms at their sides 2. Use the finger pads of one hand to palpate 3. Depress the client's abdomen using dipping motion 4. Move fingers across client's abdomen moving clockwise 5. Palpate painful areas

A nurse is preparing to perform an assessment on a client's abdomen. Which of the following piece of equipment should the nurse use? Select all that apply. A. Stethoscope B. Watch C. Tape measure D. Reflex hammer E. Tuning fork

A. Stethoscope B. Watch C. Tape measure The nurse should use a stethoscope to auscultate the client's abdominal area to listen for bowel and vascular sounds. The nurse should use a watch or clock to time the intervals of bowel sounds detected. The nurse should use a tape measure to measure the client's abdominal circumference if their abdomen is distended.

A nurse is providing dietary teaching to a client about the purpose of incorporating fiber in their diet. Which of the following information should the nurse include? A. Fiber can be found in most dairy products. B. Fiber allows larger stool to soften and pass easier. C. Fiber decreases peristalsis to prevent diarrhea. D. Fiber promotes the growth of good bacteria in the intestinal tract.

B. Fiber allows larger stool to soften and pass easier. Fiber absorbs water in the intestinal tract, which allows larger stool to soften and pass more easily.

A nurse is providing teaching to a client about health promotion to prevent constipation. Which of the following instructions should the nurse include? A. "Limit vegetables to 10% of your daily intake." B. "Drink 32 ounces of water per day." C. "Eliminate legumes from your diet." D. "Consume foods that are high in whole grains."

D. "Consume foods that are high in whole grains." The nurse should instruct the client to consume foods that are high in whole grains, such as high-fiber cereals and legumes.

A nurse is preparing to auscultate a client's abdomen. Which of the following should the nurse expect if the client is experiencing borborygmus? A. Hypoactive bowel sounds B. Absent bowel sounds C. Hyperactive bowel sounds D. Normative bowel sounds

C. Hyperactive bowel sounds The nurse should identify that borborygmi bowel sounds are hyperactive bowel sounds that are auscultated about every 3 sec due to increased peristalsis of the bowels, as with diarrhea. Borborygmi bowel sounds are louder and have a rushing, rumbling, or tinkling sound.

A nurse is teaching a client about the purpose of probiotics and incorporating them in their diet. Which of the following information should the nurse provide? A.Probiotics increase peristalsis to prevent constipation. B. Probiotics allow larger stool to soften to pass. C. Probiotics promote the growth of good bacteria in the client's intestinal tract. D. Probiotics remove fats and waste products from the body.

C. Probiotics promote the growth of good bacteria in the client's intestinal tract. The nurse should include that probiotics promote the growth of good bacteria in the intestinal tract to balance with the bad bacteria. This can relieve intestinal discomfort, such as diarrhea or constipation.

A nurse is auscultating a client's abdomen for the presence of bowel sounds. Which of the following findings should the nurse expect for hypoactive bowel sounds? A. Bowel sounds absent after 5 min B. Bowel sounds auscultated every 5 to 30 seconds C. Bowel sounds auscultated every 3 seconds D. Bowel sounds heard after 2 min

D. Bowel sounds heard after 2 min The nurse should identify that hypoactive bowel sounds are auscultated after 1 min and up to 5 min for presence of bowel sounds. This can be related to decreased peristalsis due to constipation, adverse effects of medication, anesthesia, or an intestinal obstruction.

A nurse is preparing to obtain information regarding a client's abdominal health history. Which of the following questions should the nurse ask? Select all that apply. A. "Are you experiencing abdominal pain?" B. "Do you take any medication?" C. "Have you noticed a change in your appetite?" D. "When was your last bowel movement?" E. "Have you had any changes in your urinary output?"

A. "Are you experiencing abdominal pain?" B. "Do you take any medication?" C. "Have you noticed a change in your appetite?" D. "When was your last bowel movement?" The nurse should ask the client to locate the pain, describe it, rate the intensity of the pain on a scale from 0 to 10, and report how long they have been experiencing the pain. The nurse should ask the client about any medications they are taking because medications can affect a client's abdomen, such as distention, discomfort, nausea or vomiting. This can confirm weight loss or gain along with irritation of the bowel if the client is experiencing decreased hunger, nausea, or vomiting. This allows the nurse to collect information on the client's bowel habits. The nurse can also ask about color and consistency of the client's stool at this time. The nurse can also ask about color and consistency of the client's stool at this time.

A nurse is preparing to inspect a client's abdomen who has liver disease. Which of the following manifestations should the nurse expect? A. Dilated veins B. Stretch marks C. Purple striae D. Rash

A. Dilated veins The nurse should identify that dilated veins and spider angiomas on the client's abdomen are manifestations of liver disease.

A nurse is preparing to inspect a male client's abdomen. Which of the following findings should the nurse identify is an unexpected finding? Select all that apply. A. Everted umbilicus B. Purple Striae C. Rash D. Healed Scars E. Mole

A. Everted umbilicus B. Purple Striae C. Rash The nurse should identify that eversion of the umbilicus is an unexpected finding when inspecting a client's abdomen, which can indicate conditions such as an abdominal mass or obesity. The nurse should identify that purple striae is an unexpected finding when inspecting a client's abdomen, which can be an indication of weight gain or loss, abdominal distention, or a manifestation of Cushing syndrome. The nurse should identify that a rash is an unexpected finding when inspecting a client's abdomen, which can be an indication of an allergic reaction or a manifestation of a condition the client may have.

A nurse is providing teaching to a client about screening prevention for colorectal cancer. Which of the following tests should the nurse include? Select all that apply A. Fecal occult test B. Flex sigmoidoscopy C. Colonoscopy D. Barium enema with contrast E. Bronchoscopy

A. Fecal occult test B. Flex sigmoidoscopy C. Colonoscopy D. Barium enema with contrast A fecal occult test screens for blood in the stool, which can detect ulceration in the colon. A flex sigmoidoscopy is performed to visualize the rectum and descending. A colonoscopy is performed to visualize the rectum and large intestines. A barium enema with contrast is performed to visualize the large intestines using x-ray and contrast dye.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which of the following quadrants should the nurse listen to first? A. Right lower quadrant B. Left lower quadrant C. Right upper quadrant D. Left upper quadrant

A. Right lower quadrant According to evidence-based practice, the nurse should first auscultate the client's right lower quadrant to determine the presence of bowel sounds. The presence of bowel sounds is typically found in the right lower quadrant, which is located at the ileocecal valve because bowel sounds are transmitted through the abdomen.

A nurse is preparing to inspect a client's abdomen. Which of the following variations should the nurse expect to find? Select all that apply. A. Silver striae B. Rash C. Taut skin D. Healed scars E. Mole

A. Silver striae D. Healed scars E. Mole The nurse should identify that silver striae is an expected finding when inspecting a client's abdomen, which can be an indication of a previous pregnancy.

A nurse is preparing to inspect the umbilicus of a client's abdomen. Which of the following findings should the nurse identify as an unexpected finding? A. Swelling B. Mole C. Extraversion D. Scar

A. Swelling The nurse should identify that swelling of the umbilicus can be an indication of a hernia, which is a protrusion of the abdominal viscera through an abnormal opening in the client's muscle wall.

A nurse is preparing to assess a client's abdomen. Upon palpation, which of the following findings should the nurse report to the provider? A. Nontender B. Involuntary Rigidity C. Relaxed Muscles D. Adipose Tissue

B. Involuntary Rigidity Involuntary ridigity might be present when the client's abdomen feels boardlike, hardness, or pain along with muscle rigidty. This could be an indication that the client has an abdominal mass or an acute inflammation of the peritoneum, and should be reported to the provider.

A nurse is preparing to palpate a client's abdomen. Which of the following findings should the nurse expect? A. Involuntary rigidity B. Voluntary guarding C. Boardlike D. Nontender

D. Nontender The nurse should expect the client's abdomen to be nontender, and muscles relaxed upon palpation.