Abdominal Assessment

A client has experienced hematemesis, what is this? a) Blood in the urine b) Blood in the vomit c) Blood in the stool d) Blood in the sputum

b) Blood in the vomit

The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a) gallbladder disease. b) overuse of laxatives. c) gastrointestinal bleeding. d) localized bleeding around the anus.

c) gastrointestinal bleeding.

The nurse realizes which structure of the GI system is the primary site of absorption? a) Stomach b) Duodenum c) Large intestine d) Sigmoid e) Small intestine

e) Small intestine

1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance

ANS: A The liver is located in the right upper quadrant and would elicit a dull percussion note

30. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? A) Dullness across the abdomen B) Flatness in the right upper quadrant C) Hyperresonance in the left upper quadrant D) Tympany in the right and left lower quadrants

ANS: A The presence of fluid causes a dull sound to percussion. A large amount of ascitic fluid would produce a dull sound to percussion

15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: A) diarrhea. B) pyrosis. C) dysphagia. D) constipation.

ANS: B Pyrosis, or heartburn (not constipation), is caused by esophageal reflux during pregnancy. The other options are not correct

31. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? A) "No need to worry. Most men your age develop hernias." B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." C) "This hernia is a result of prenatal growth abnormalities that are just now causing problems." D) "I'll have to have your physician explain this to you."

ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall

14. During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line

ANS: B Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line)

41. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A. Test for Murphy's sign. B. Test for Blumberg's sign. C. Test for shifting dullness. D. Perform iliopsoas muscle test. E. Test for fluid wave.

ANS: B, D Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites

26. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? A) A bruit is absent. B) Femoral pulses are increased. C) A pulsating mass is usually present. D) Most are located below the umbilicus.

ANS: C Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline

9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.

ANS: C Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.

40. During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms? A) Appendicitis B) Gastric ulcer C) Duodenal ulcer D) Cholecystitis

ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal, yet it is relieved by more food. Chronic pain associated with gastric ulcers occurs usually on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis

18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: A) ovary infection. B) liver enlargement. C) kidney inflammation. D) spleen enlargement.

ANS: C Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct

22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? A) Spleen B) Sigmoid C) Appendix D) Gallbladder

ANS: C The appendix is located in the right lower quadrant, and when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant

37. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumor

ANS: C The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: A) obese. B) herniated. C) scaphoid. D) protuberant.

ANS: D A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7. A scaphoid abdomencaves inward

32. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should: A) document the presence of hepatomegaly. B) ask additional history questions regarding his alcohol intake. C) describe this as an enlarged liver and refer him to a physician. D) consider this a normal finding and proceed with the examination.

ANS: D The average liver span in the midclavicular line is 6 to 12 cm. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 10 cm is within normal limits for this individual

The 79-year-old female tells the nurse, "I don't drink as much water as I should because it makes me have to go to the bathroom." What is this client prone to developing? a) Constipation b) Hemorrhoids c) Diarrhea d) Acid indigestion

a) Constipation

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a) Dullness b) Tympany c) Resonance d) Hyperresonance

a) Dullness

Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a) "It should fall off by 10 to 14 days." b) "It will soften before it falls off." c) "It contains two veins and one artery." d) "Skin will cover the area within 1 week."

a) "It should fall off by 10 to 14 days."

The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? a) African-Americans b) Hispanics c) Whites d) Asians

a) African-Americans

While assessing the abdomen, the nurse palpates a pulsating mass. The nurse interprets this finding as an abdominal aneurysm. What other assessment findings would the nurse expect? (Select all that apply) a) An epigastric bruit b) Femoral pulses are increased c) Femoral pulses are decreased d) Hypoactive bowel sounds e) Cool extremities

a) An epigastric bruit c) Femoral pulses are decreased e) Cool extremities

The nurse is planning to assess the abdomen of an adult male. What should be done first? a) Ask client to empty bladder b) Place the client in side-lying position c) Ask client to hold his breath for a few seconds d) Tell client to raise arms above the head

a) Ask client to empty bladder

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a) Dullness across the abdomen b) Flatness in the right upper quadrant c) Hyperresonance in the left upper quadrant d) Tympany in the right and left lower quadrants

a) Dullness across the abdomen

Which organs are located in the right upper quadrant? Select all that apply a) Liver b) Gallbladder c) Duodenum d) Head of pancreas e) Spleen f) Right adrenal gland

a) Liver b) Gallbladder c) Duodenum

Which of these are accessory organs to the GI system? Select all that apply a) Liver b) Spleen c) Pancreas d) Kidney e) Gallbladder f) Salivary glands

a) Liver c) Pancreas e) Gallbladder f) Salivary glands

After assessing a client, the nurse writes "striae present bilateral costal margins." What should the nurse do with this information? a) Nothing. This is a normal finding. b) Suggest the client see a general surgeon. c) Ask the client if they've experienced any recent emotional events. d) Notify the physician.

a) Nothing. This is a normal finding.

The colon originates in this abdominal area of the a) Right lower quadrant b) Right upper quadrant c) Left lower quadrant d) Left upper quadrant

a) Right lower quadrant

To percuss the liver of an adult, where should the nurse begin the assessment? a) Right upper quadrant b) Right lower quadrant c) Left upper quadrant d) Left lower quadrant

a) Right upper quadrant

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a) Spleen b) Sigmoid colon c) Appendix d) Gallbladder

a) Spleen

What is hematemesis evidence of? a) Stomach ulcers b) Pancreatic ulcers c) Decreased gastric motility d) Abdominal tumors

a) Stomach ulcers

The primary function of the gallbladder is to a) Store and excrete bile b) Aid in the digestion of protein c) Produce alkaline hormones d) Produce hormones

a) Store and excrete bile

If a clients umbilicus is enlarged and to the left - what is this indicitive of? a) Umbilical hernia b) Ascites c) Intraabdominal bleeding d) Pancreatitis

a) Umbilical hernia

During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to: a) an enlarged liver. b) an enlarged spleen. c) distended bowel. d) excessive diarrhea.

a) an enlarged liver.

The symptoms occurring with lactose intolerance include: a) bloating and flatulence. b) gray stools. c) hematemesis. d) anorexia.

a) bloating and flatulence.

Older adults have: a) decreased salivation leading to dry mouth. b) increased gastric acid secretion. c) increased liver size. d) decreased incidence of gallstones.

a) decreased salivation leading to dry mouth.

A nurse notices that a patient has ascites, which indicates the presence of: a) fluid. b) feces. c) flatus. d) fibroid tumors.

a) fluid.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: a) projectile vomiting. b) hypoactive bowel activity. c) palpable olive-sized mass in right lower quadrant. d) pronounced peristaltic waves crossing from right to left.

a) projectile vomiting.

Shifting dullness is a test for: a. Ascites b. Splenic enlargement c. Inflammation of the kidney d. hepatomegaly

a. Ascites

Auscultation of the abdomen may reveal bruits of the ___ arteries. a. aortic, renal, iliac, and femoral b. jugular, aortic, carotid, and femoral c. pulmonic, aortic, and portal d. renal, iliac, internal jugular, and basilic

a. aortic, renal, iliac, and femoral

Auscultation of the abdomen is begun in the right lower quadrant (RLQ) because: a. bowel sounds are always normaly present here b. peristalsis through the descending colon is usually active c. tis is the location of the pyloric sphincter d. vascular sounds are best heard in this area

a. bowel sounds are always normaly present here

Right upper quadrant tenderness may indicate pathology in the: a. liver, pancreas, or ascending colon b. liver and stomach c. sigmoid colon, spleen, or rectum d. appendix or ileocecal valve

a. liver, pancreas, or ascending colon

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a) "We need to determine areas of tenderness before using percussion and palpation." b) "It prevents distortion of bowel sounds that might occur after percussion and palpation." c) "It allows the patient more time to relax and therefore be more comfortable with the physical examination." d) "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation."

b) "It prevents distortion of bowel sounds that might occur after percussion and palpation."

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: a) 1 minute. b) 5 minutes. c) 10 minutes. d) 2 minutes in each quadrant.

b) 5 minutes.

The abdomen normally moves when breathing until the age of ____ years. a) 4 b) 7 c) 14 d) 75

b) 7

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a) Obturator test b) Test for Murphy's sign c) Assess for rebound tenderness d) Iliopsoas muscle test

b) Test for Murphy's sign

The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true? a) The abdominal tone is increased. b) The abdominal musculature is thinner. c) Abdominal rigidity with acute abdominal conditions is more common. d) The aging person complains of more pain with an acute abdominal condition than a younger person would.

b) The abdominal musculature is thinner.

A nurse is listening to bowel sounds. Which of the following is true of bowel sounds? a) They are usually loud, high-pitch , rushing, tinkling b) They are usually high-pitched, gurgling, irregular c) They are usually low-pitched, gurgling, regular d) They are usually low-pitched and irregular

b) They are usually high-pitched, gurgling, irregular

A client comes to the hospital with nausea, vomiting, and ongoing sciatic pain. Which of the following should be included in the focus interview with this client? a) Bowel habits b) Use of pain medication c) Blood pressure levels d) Review of other chronic diseases

b) Use of pain medication

Pyrosis is: a) an inflammation of the peritoneum. b) a burning sensation in the upper abdomen. c) a congenital narrowing of the pyloric sphincter. d) an abnormally sunken abdominal wall.

b) a burning sensation in the upper abdomen.

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a) increased gastric acid secretion. b) decreased gastric acid secretion. c) delayed gastrointestinal emptying time. d) increased gastrointestinal emptying time.

b) decreased gastric acid secretion.

The nurse knows that during an abdominal assessment, deep palpation is used to determine: a) bowel motility. b) enlarged organs. c) superficial tenderness. d) overall impression of skin surface and superficial musculature.

b) enlarged organs.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a) examine the tender area first. b) examine the tender area last. c) avoid palpating the tender area. d) palpate the tender area first and then auscultate for bowel sounds.

b) examine the tender area last.

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a) diarrhea. b) peritonitis. c) laxative use. d) gastroenteritis.

b) peritonitis.

Murphy's sign is best described as: a. the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix b. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder c. a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle d. not a valid examination technique

b. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a) A bruit is absent. b) Femoral pulses are increased. c) A pulsating mass is usually present. d) Most are located below the umbilicus.

c) A pulsating mass is usually present.

The nurse assessing an older client who has lost 5 lbs since her last visit 1 year ago. The client tells the nurse her husband died 2 months ago. The nurse should assess for a) Peptic ulcer b) Bulimia c) Appetite changes d) Pancreatic disorders

c) Appetite changes

The pancreas of an adult is located a) Below the diaphragm and below right costal margin b) High and deep under the diaphragm - can't be palpated c) Deep in the upper adbomen and is not normally palpable d) Posterior to the left midaxillary line and posterior to the stomach

c) Deep in the upper adbomen and is not normally palpable

A client tells the nurse, "I get stomach burning when I drink wine." Of what is this information an indication? a) Gallstones b) Intestinal ulcerations c) Gastrointestinal irritation d) Stomach bleeding

c) Gastrointestinal irritation

The nurse is planning to palpate a client's bladder. Which area of the abdomen should this palpation be done? a) Right hypochondriac region b) Left lumbar region c) Hypogastric region d) RLQ

c) Hypogastric region

The nurse is aware that the correct procedure for an abdominal assessment is? a) Inspection, palpation, percussion, auscultation b) Inspection, percussion, palpation, auscultation c) Inspection, auscultation, percussion, palpation d) Inspection, palpation auscultation, percussion

c) Inspection, auscultation, percussion, palpation

To palpate the spleen, where should you begin the assessment? a) Right upper quadrant b) Right lower quadrant c) Left upper quadrant d) Left lower quadrant

c) Left upper quadrant

To palpate tenderness of an adult's appendix, where should you begin? a) Left lower quadrant b) Left upper quadrant c) Right lower quadrant d) Right upper quadrant

c) Right lower quadrant

The client tells the nurse, "I've had diarrhea ever since my mother was admitted to the hospital with a heart attack." What can the nurse say to the client about this information? a) Are you having any other problems? b) What hospital is your mother in? c) Stress can cause the bowels to act up. d) How's your mother doing now?

c) Stress can cause the bowels to act up.

The nurse is preparing to examine a client's abdomen. Which of the following landmarks could be considered a thoracic structure? a) Umbilicus b) Iliac crests c) Xiphoid process d) Pubic bone

c) Xiphoid process

Pyloric stenosis is a(n): a) abnormal enlargement of the pyloric sphincter. b) inflammation of the pyloric sphincter. c) congenital narrowing of the pyloric sphincter. d) abnormal opening in the pyloric sphincter.

c) congenital narrowing of the pyloric sphincter.

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: a) aphasia. b) dysphasia. c) dysphagia. d) anorexia.

c) dysphagia.

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a) flatness, resonance, and dullness. b) resonance, dullness, and tympany. c) tympany, hyperresonance, and dullness. d) resonance, hyperresonance, and flatness.

c) tympany, hyperresonance, and dullness.

The four layers of large, flat abdominal muscles form the: a) linea alba. b) rectus abdominus. c) ventral abdominal wall. d) viscera.

c) ventral abdominal wall.

Tenderness during abdominal palpation is expected when palpating: a. the liver edge b. the spleen c. the sigmoid colon d. the kidneys

c. the sigmoid colon

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a) The spleen can be enlarged as a result of trauma. b) The spleen is normally felt upon routine palpation. c) If an enlarged spleen is noticed, then the nurse should palpate thoroughly to determine size. d) An enlarged spleen should not be palpated because it can rupture easily.

d) An enlarged spleen should not be palpated because it can rupture easily.

If assessing a client for kidney tenderness, where would you begin? a) Right upper quadrant b) Left upper quadrant c) External oblique angle d) Costovertebral angle

d) Costovertebral angle

The nurse is aware that a change may occur in the GI system of an aging adult is? a) Increased saliva b) Decreased peristalsis c) Increased esophageal emptying d) Decreased gastric acid secretion

d) Decreased gastric acid secretion

The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem? a) Hypertension b) Streptococcus infections c) History of constipation and frequent laxative use d) Frequent use of nonsteroidal anti inflammatory drugs

d) Frequent use of nonsteroidal anti inflammatory drugs

The nurse is preparing to assess the abdomen of a hospitilized client 2 days after abdominal surgery. The nurse should first a) Palpate the incision site b) Auscultate for bowel sounds c) Percuss for tympany d) Inspect the abdominal area

d) Inspect the abdominal area

The physician has ordered a urinalysis, but the patient states "I don't have to go now." The nurse is concerned about urinary retention and palpates the bladder for distention. How should the nurse assess for this condition? a) Percuss and palpate the lumbar region b) Inspect and palpate the epigastric region c) Auscultate and percuss the inguinal region d) Percuss and palpate the hypogastric region

d) Percuss and palpate the hypogastric region

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a) Percuss and palpate in the lumbar region. b) Inspect and palpate in the epigastric region. c) Auscultate and percuss in the inguinal region. d) Percuss and palpate the midline area above the suprapubic bone.

d) Percuss and palpate the midline area above the suprapubic bone.

To detect diastasis recti, the nurse should have the patient perform which of these maneuvers? a) Relax in the supine position. b) Raise the arms in the left lateral position. c) Raise the arms over the head while supine. d) Raise the head while remaining supine.

d) Raise the head while remaining supine.

Which structure is located in the left lower quadrant of the abdomen? a) Liver b) Duodenum c) Gallbladder d) Sigmoid colon

d) Sigmoid colon

The nurse auscultates borborygmi on a client. What does this finding indicate to the nurse? a) The client is anorexic. b) The client had a full breakfast. c) The client is obese. d) The client is hungry.

d) The client is hungry.

The mother of an 18-month-old child tells the nurse, "I can see his belly rumbling. Is this normal?" Which of the following can the nurse respond to this client? a) No. This is not normal. b) There is a good pediatric gastroenterologist that I know who can help you. c) This means his gallbladder is digesting fats. d) The muscles of the abdomen are thin in babies. So you will see this.

d) The muscles of the abdomen are thin in babies. So you will see this.

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a) splenomegaly. b) distended bladder. c) constipation. d) ascites.

d) ascites.

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile. a) flat b) convex c) bulging d) concave

d) concave

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a) a loud continuous hum. b) a peritoneal friction rub. c) hypoactive bowel sounds. d) hyperactive bowel sounds.

d) hyperactive bowel sounds.

Methods to enhance abdominal wall relaxation during examination include: a) a cool environment. b) having the patient place arms above the head. c) examining painful areas first. d) positioning the patient with the knees bent.

d) positioning the patient with the knees bent.

The range of normal liver span in the right midclavicular line in the adult is: a. 2-6 cm b. 4-8 cm c. 8-14 cm d. 6-12 cm

d. 6-12 cm

Hyperactive bowel sounds are: a. High pitched b. Rushing c. Tinkling d. All of the above

d. All of the above

A dull percussion note forward of the left midaxillary line is: a. normal, an expected finding during splenic percussion b. expected between the 8th and 12th ribs c. found if the examination follows a large meal d. indicative of splenic enlargement

d. indicative of splenic enlargement

Striae, which occur when the elastic fibers in the reticular layer of the skin are broken following rapid or prolonged stretching, have a distinct color when of long duration. This color is: a. pink b. blue c. purple-blue d. silvery white

d. silvery white