Abdominal Assessment

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

Abdominal aortic aneurysm

Why is the appearance of urine important to evaluate during an abdominal examination?

Cloudy urine may indicate UTI. Sediment may indicate kidney disease. Blood can be caused from renal injury, renal disease, or trauma to a catheter. Dark urine may be from dehydration.

Which assessment questions are appropriate for people of Native American descent? Select all that apply.

Do you drink alcohol? If so, how much and how often?, Have you ever had yellow skin or yellow eyes?, Have you had liver disease, gallbladder disease, or pancreatitis?, Do you have diabetes? Alcoholism, diabetes, liver and gallbladder diseases, and pancreatitis are more prevalent in the Native American population.

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

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.

The nurse is assessing an older adult client for severe malnutrition. Which of the following factors increases this client's risk for malnutrition?

Limited access to a grocery store

Some changes that appear on the skin of the abdomen as a result of pregnancy are what? Select all that apply.

Linea nigra, Everted umbilicus, Striae

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

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

A client has a history of multiple abdominal surgeries from a gunshot wound 3 years ago. The client is currently reporting severe abdominal pain. Auscultation reveals high-pitched, rushing sounds. These sounds could be a sign of what condition?

Partial bowel obstruction

The client with a acute appendicitis has been ordered a barium enema. What should the nurse do first?

Question the order as a barium enema is contraindicated in acute appendicitis ( A barium enema should not be performed on a client suspected of having an acute inflammatory condition, such as appendicitis, diverticulitis, or ulcerative colitis, or who has a perforated hollow organ. The barium enema can cause an inflamed area of the bowel to rupture and death may result.)

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 preparing to palpate the client's spleen. What should the nurse instruct the client to do?

Take a deep breath and exhale

The nurse is assessing an adult client with severe abdominal pain and asks the client if they have had any prior surgeries. The client states that she had a hysterectomy 20 years ago. Why is this information relevant? Select all that apply.

The information shows increased risk for adhesions, The information shows increased risk for obstructions, The information shows increased risk for malabsorption