Assessment Chap 21 Abdoment
It is often difficult to distinguish between an enlarged kidney and an enlarged spleen. Which characteristic helps the nurse identify an enlarged kidney?
Percussion is tympanitic
While assessing bowel sounds in a patient, the nurse observes that the sounds have diminished. What disease can the nurse anticipate from the findings?
Peritonitis
What finding does the nurse document after inspecting the abdomen of a patient with obesity?
Uniformly rounded with sunken umbilicus
The nurse is teaching a class about assessing bowel sounds. Which statement made by a student nurse indicates the need for further teaching?
"Listen to bowel sounds in all four quadrants."
The nurse is assessing a patient with an enlarged spleen as a nursing student watches. Which statement by the student indicates a need for more teaching?
"The spleen should be continuously palpated."
The nurse is caring for a patient with irritable bowel syndrome (IBS). What are the expected assessment findings for this patient?
1,2,3
The nurse is caring for a newborn with an umbilical hernia. What should the nurse teach the parents before the infant is discharged from the health care facility?
1,2,4
During the assessment of a teenager, what findings does the nurse relate to anorexia nervosa?
1,2,5
The nurse is assessing a patient who complains of abdominal pain within an hour of eating. Which further assessment findings would confirm gastroesophageal reflux disease (GERD)?
1,2,5
The internal organs of the abdomen are called viscera. Which organs constitute the solid viscera?
1,3,4
What are the normal features of the spleen?
1,3,5
The nurse is preparing a patient for an abdominal examination. What are the procedures the nurse should follow?
1,4
The nurse is assessing a patient with abdominal pain. What characteristics of the pain does the nurse relate to a duodenal ulcer?
2,3,4
What are the changes in the gastrointestinal system due to aging?
2,3,4
What assessment finding does the nurse relate to the presence of a large ovarian cyst that is found during a patient's abdominal examination?
2,4,5
While assessing a patient with abdominal distention, the nurse observes that the shape of the abdomen is like a single round curve. On palpation, the nurse detects a muscle spasm of the abdominal wall. What is the likely cause of the abdominal distention?
air
The nurse is preparing to assess the abdomen of a patient. What measures must the nurse take while examining the abdominal muscles?
3,4,5
What findings during an assessment should the nurse associate with malnutrition?
3,4,5
The nurse is preparing to examine the abdomen of a patient who is supine on the examination table. What observation does the nurse associate with abdominal pain?
Absolute stillness
The nurse observes rebound tenderness in the abdomen of a patient. What condition does this finding indicate?
Appendicitis
The nurse is assessing a patient with increased abdominal girth and notes tympany at the top of the abdomen during percussion. What condition does the nurse relate to this finding?
Ascites
Which intervention is used to determine Murphy sign?
Ask the patient to take a deep breath while holding the fingers under the liver border.
What precaution does the nurse take while auscultating the abdomen of a patient?
Auscultate using the diaphragm endpiece
The nurse elicits tenderness while palpating a patient's abdomen. Which assessment does the nurse use to confirm rebound tenderness?
Blumberg sign
While assessing a 35-year-old patient, the nurse hears a vascular sound between the xiphoid process and the umbilicus. What can the nurse presume from the sound?
Bruits
A patient is admitted with a sudden pain in the right upper quadrant (RUQ) that radiates to the right or the left scapula. The patient is also reports nausea and vomiting. On reviewing the patient's diet, the nurse learns the patient is fond of both fatty foods and alcohol. What does the nurse suspect from these symptoms and findings?
Cholecystitis
The nurse is caring for a patient with pain in the right lower quadrant (RLQ). The patient's Alvarado score is 8. What is the probable diagnosis for this patient?
Diagnosis of appendicitis
What problem does the nurse expect to find in a patient with dysphagia
Difficulty in swallowing
The nurse places the stethoscope over the xiphoid process while lightly stroking the skin with one finger up the midclavicular line from the right lower quadrant (RLQ). Which test is the nurse performing in the patient?
Doing a scratch test
The nurse palpates a small, fatty nodule through the linea alba on the abdomen when the patient is standing. What term does the nurse use to document this finding?
Epigastric hernia
Which condition in a patient hinders the accurate detection of liver borders?
Gas distention
A patient reports a dull pain in the right upper quadrant (RUQ) of the abdomen. On further assessment, the nurse detects general malaise, anorexia, and nausea in the patient. What does the nurse suspect from these signs and symptoms?
Hepatitis
Which test does the nurse use to assess a patient with suspected appendicitis pain?
Iliopsoas muscle test
While assessing a patient with a distended abdomen, the nurse observes marked visible peristalsis. What is the most probable cause of this finding?
Intestinal obstruction
Which feature is specific to the right kidney?
It may be palpable sometimes.
The nurse is assessing a patient who reports sudden onset of pain in the lower abdomen. What is the most probable cause of the pain?
Kidney Stones
The nurse is assessing the abdomen of a patient with late portal cirrhosis. What is the most probable finding during palpation?
Liver is nodular and enlarged
The nurse teaches a patient who is prescribed iron supplements about the change in the color of stool. What color should the patient expect?
Nontarry, black stool
While caring for a patient with a feeding tube, which assessment must the nurse use to confirm the feeding tube's position?
Obtain a chest x-ray
While assessing a 4-year-old patient, the nurse observes the abdomen of the child has a scaphoid shape. What is the possible cause of the shape?
dehydration
The nurse notes frictional rub while auscultating over the lower right rib cage. What does the nurse infer from this finding?
Presence of an abscess in the liver
What does the nurse find on assessing the abdomen of a patient with ascites?
Presence of an everted umbilicus
What assessment finding will the nurse document in a patient with an aortic aneurysm? Presence of bruit on auscultation Presence of normal femoral pulses Presence of a smooth, sausage-like mass Presence of a small liver with firm edges
Presence of bruit on auscultation Rationale The nurse notes bruits over the aorta on auscultation with firmer pressure in a patient with an aortic aneurysm. The nurse will feel the presence of decreased femoral pulses over the femoral arteries. Most aortic aneurysms are located below the renal arteries and extend to the umbilicus. Focal bulging may be palpable and feel like a pulsating mass in the upper abdomen just to the left of midline. An enlarged, nontender gallbladder feels like a smooth, sausage-like mass. The nurse may feel the presence of a small liver with firm edges in a patient with cirrhosis, not in a patient with an aortic aneurysm.
Which finding should the nurse relate to Cushing syndrome during an assessment?
Presence of purple-blue striae
The nurse is assessing an infant who is being rocked from side to side. The nurse auscultates a very loud splash in the upper abdomen. What is the most probable cause of this finding?
Pyloric obstruction
Which quadrant should the nurse assess in a pregnant patient for pain related to appendicitis? Right Upper Quadrant (RUQ) Right Lower Quadrant (RLQ) Left Upper Quadrant (LUQ) Left Lower Quadrant (LLQ)
Right Lower Quadrant (RLQ) Rationale The pregnant patient will feel appendicitis pain in the right lower quadrant (RLQ), because that is where the appendix is located. During pregnancy, the enlarging uterus may displace the appendix upward and to the right. However, the patient will still feel any appendicitis-related pain in the RLQ, not the right upper quadrant (RUQ). The patient does not experience any referred pain; therefore, the pain is not felt in the left upper quadrant (LUQ) or the left lower quadrant (LLQ).
What should the nurse do to assess the symmetry of the patient's abdomen?
Shine a light lengthwise across the patient
Which organ is located in all four quadrants of the abdomen? Liver Ovary Stomach Small Intestine
Small Intestine Rationale The abdominal wall is divided into four quadrants by imaginary vertical and horizontal lines bisecting the umbilicus. The small intestine extends from the pyloric valve of the stomach to the ileocecal valve, where it joins the colon. Thus, the small intestine is located in all four quadrants. The liver occupies most of the right upper quadrant. The right ovary and tube lie in the right lower quadrant, whereas the left ovary and tube lie in the left lower quadrant. The stomach is in the left upper quadrant. p. 538
What should the nurse expect to find while assessing the abdomen of a patient with chronic emphysema?
The liver appears to be displaced downward.
Which finding during an abdominal assessment does the nurse associate with mononucleosis?
The spleen feels soft with rounded edges.
Which finding of an umbilical cord during a newborn's assessment is cause for concern?
The umbilical cord has an artery and a vein.
Which finding during the abdominal assessment of a newborn needs further investigation?
Venous hum
Which organs are located at the right upper quadrant (RUQ) in the abdomen?
the liver, gallbladder, and duodenum
Which statements would the nurse include when teaching an aging adult about prevention of constipation? "Include high-fat food in the diet." "Include low-fiber foods in the diet." "Do not retain stool deliberately." "Participate in physical exercise." "Drink an adequate quantity of water."
~"Do not retain stool deliberately." ~"Participate in physical exercise." ~"Drink an adequate quantity of water." Rationale In order to prevent constipation, the patient should drink adequate water to ease digestion and prevent hardening of stools. The aging adult often retains stool deliberately due to difficulty in ambulating to the toilet. This makes the stool hard and difficult to pass. Therefore, the nurse should encourage the patient to use the toilet when required. Because lack of mobility and physical exercise leads to constipation, the nurse should ask the patient to engage in physical activity to promote bowel movements. The nurse should not encourage increased intake of high-fat food, which can lead to obesity. The patient should include high-fiber food in the diet to prevent constipation. p. 541
