CH: 23 Assessing Abdomen
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 regards to this finding?
"How many times have you been pregnant?"
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?
Abdominal aortic aneurysm Pulsation of the aorta may be increased and lateralized in an abdominal aortic aneurysm. Ascites is collection of fluid in the abdomen. Inflammation and tumors do not pulsate.
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit Auscultation of the abdomen would reveal a bruit. The client may exhibit decreased femoral pulses, hypotension and cool extremities.
A client complains of a burning sensation in the esophagus after eating. Which associated condition should the nurse most suspect?
Acid reflux The onset of pain is a diagnostic clue to its origin. For example, acute pancreatitis produces sudden onset of pain, whereas the pain of pancreatic cancer may be gradual or recurrent. A client may have excessive gas after ingesting certain foods. A burning sensation in the esophagus may occur with gastric acid reflux after eating. Pain related to gastric ulcers may occur when the stomach is empty.
The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what?
Appendicitis RLQ pain constitutes a positive obturator sign, suggesting an inflamed appendix or peritoneal inflammation.
The nurse would assess for positive Blumberg sign how?
Applying and releasing pressure to the abdomen Pain that occurs after applying and releasing pressure to the abdomen would be a positive Blumberg sign. Murphy sign occurs when the client holds his breath and there is pain. Blunt pressure at the CVA assesses for kidney pain. Liver span test occurs at the MCL.
A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action?
Ask the client when the pain began. If a patient has an acute abdominal problem, the history and physical examination will be focused on that problem, so that much of the history taking will be eliminated. Severe dehydration from nausea and vomiting, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Pain is the chief complaint and should be assessed before a diet recall, obtaining a health history, and identifying risk factors.
When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding?
Bowel sounds normal Normal bowel sounds consist of clicks and gurgles that occur at an estimated frequency of 5 to 30 per minute
The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what?
Bruit Bruits are swishing sound that indicate turbulent blood flow.
A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client?
Constipation related to decrease in fluid intake The nurse can confirm constipation because the major defining characteristics of decreased frequency and abdominal discomfort are present. A few days of altered nutrition does not meet the necessary criteria to confirm Ineffective Nutrition or Risk for Fluid Volume Deficit. Ineffective Health Maintenance cannot be confirmed because there is no evidence that the client lacks the knowledge to eat properly. Reference:
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?
Crohn's disease 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.
The nurse is performing an assessment on a client that is on postop day 2. The abdominal wound has pulled apart and the contents are spilling out. The nurse recognizes this as a what?
Dehiscence
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?
Family history; dietary habits Poor diet and a family history are both identified as risk factors for colorectal cancer
On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity?
Fluid accumulation
A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause?
Helicobacter pylori Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucous, on occasion the H. pylori disrupt the mucous lining and inflame the organ lining.
What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen?
Hypogastric The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbical, left lumbar, right inguinal, hypogastric, and left inguinal.
The nurse as elicited a positive Murphy sign. The knows this is indicates what?
Inflammation of the gallbladder Pain with breathing during while assessing Murphy sign is an indication of inflammation of the gallbladder
Your patient describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your patient?
Malabsorption syndrome Malabsorption syndrome is characterized by stool that is typically bulky, soft, light yellow to gray, mushy, greasy or oily, sometimes frothy, and particularly foul-smelling, and it usually floats in the toilet.
A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement?
Measure abdominal girth The nurse should measure abdominal girth daily to assess changes in abdominal distension.
Where is the linea alba located?
Middle of the ventral abdominal wall
How should the nurse perform blunt percussion over the liver?
Place left hand on right lower rib cage, strike it with ulnar side of right fist
A nurse is attempting to palpate the abdomen of a 6-year-old girl, but the girl is so ticklish that the nurse cannot proceed. Which of the following should the nurse do?
Place the client's hand under the nurse's hand for a few moments A ticklish client has trouble lying still and relaxing during the hands-on parts of the examination. Try to combat this using a controlled hands-on technique and by placing the client's hand under your own for a few moments at the beginning of palpation. Holding hands under warm water just before the hands-on examination is done to warm the hands. Draping the client's genital area is done for modesty. Adjusting the bed level would not help with ticklishness.
A client complains of a sudden onset of pain in the back. On questioning the client further, the nurse learns that the cause of the pain is acute pancreatitis. The nurse recognizes that this type of pain is which of the following?
Referred pain Pancreatic inflammation, or pancreatitis, may be felt in the back. This is called "referred" pain because the pain is not felt at its source.
When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant?
Right kidney, ascending colon, and liver
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 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.
Rovsing's sign is a test of referred rebound tenderness in appendicitis.
True Pain in the RLQ during pressure in the LLQ is a positive Rovsing's sign. It suggests acute appendicitis.
The abdominal contents are enclosed externally by the abdominal wall musculature—three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external
abdominal oblique. The abdominal contents are enclosed externally by the abdominal wall musculature, which includes three layers of muscle extending from the back, around the flanks, to the front. The outermost layer is the external abdominal oblique.
The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area?
auscultation Auscultate the abdomen before performing percussion or palpation because these maneuvers may alter the frequency of bowel sounds. After auscultation, the order of assessment should be percussion, light palpation, and conclude with deep palpation.
The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation?
identify abdominal organs
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
To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's
right lower quadrant
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's
right upper quadrant
During an assessment, the patient describes vomiting moderate amounts that "smell like poop." The nurse might suspect
small bowel obstruction
The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?
suprapubic
A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition?
viral hepatitis
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?
visceral 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.
