Ch 38: Abdominal Assessment
A patient is scheduled for a percutaneous transhepatic cholangiography to restore biliary drainage. The nurse discusses the patient's health history and is most concerned if the patient makes which statement? "I am allergic to bee stings." "My tongue swells when I eat shrimp." "I have had epigastric pain for 2 months." "I have a pacemaker because my heart rate was slow."
"My tongue swells when I eat shrimp." The percutaneous transhepatic cholangiography procedure will include the use of radiopaque contrast medium. Patients allergic to shellfish and iodine are also allergic to contrast medium.
A patient was involved in a motor vehicle crash and reports an inability to have a bowel movement. What is the best response by the nurse? "You are just too nervous to eat or drink, so there is no stool." "Your parasympathetic nervous system is now working to slow the GI tract." "The circulation in the GI system has been increased, so less waste is removed." "Your sympathetic nervous system was activated, so there is slowing of the GI tract".
"Your sympathetic nervous system was activated, so there is slowing of the GI tract". The constipation is most likely related to the sympathetic nervous system activation from the stress related to the accident. Sympathetic nervous system activation can decrease peristalsis. Even without oral intake for a short time, stool will be formed. The parasympathetic system stimulates peristalsis. The circulation to the gastrointestinal system is decreased with stress.
The nurse is performing an abdominal assessment for a patient. Which assessment technique by the nurse is most accurate? Palpate the abdomen before auscultation. Percuss the abdomen before auscultation. Auscultate the abdomen before palpation. Perform deep palpation before light palpation.
Auscultate the abdomen before palpation. During examination of the abdomen, auscultation is done before percussion and palpation because these latter procedures may alter the bowel sounds.
A patient with a family history of adenomatous polyposis had a colonoscopy with removal of multiple polyps. Which signs and symptoms should the nurse teach the patient to report immediately? Fever and abdominal pain Flatulence and liquid stool Loudly audible bowel sounds Sleepiness and abdominal cramps
Fever and abdominal pain The patient should be taught to observe for signs of rectal bleeding and peritonitis. Fever, malaise, and abdominal pain and distention could indicate a perforated bowel with peritonitis.
A patient had a gastric resection for stomach cancer. The nurse plans to teach the patient about decreased secretion of which hormone? Gastrin Secretin Cholecystokinin Gastric inhibitory peptide
Gastrin Gastrin is the hormone activated in the stomach (and duodenal mucosa) by stomach distention that stimulates gastric acid secretion and motility and maintains lower esophageal sphincter tone. Secretin, cholecystokinin, and gastric inhibitory peptide are all secreted from the duodenal mucosa.
A patient reports severe pain when the nurse assesses for rebound tenderness. What may this assessment finding indicate? Hepatic cirrhosis Hypersplenomegaly Gallbladder distention Peritoneal inflammation
Peritoneal inflammation When palpating for rebound tenderness, the problem area of the abdomen will produce pain and severe muscle spasm when there is peritoneal inflammation. Hepatic cirrhosis, hypersplenomegaly, and gallbladder distention do not manifest with rebound tenderness.
The nurse is performing a focused abdominal assessment of a patient who has been recently admitted. In order to palpate the patient's liver, where should the nurse palpate the patient's abdomen? Left lower quadrant Left upper quadrant Right lower quadrant Right upper quadrant
Right upper quadrant Although the left lobe of the liver is located in the left upper quadrant of the abdomen, the bulk of the liver is located in the right upper quadrant.
The nurse is assessing an alert and independent 78-yr-old patient for malnutrition risk. Which is the most appropriate initial question? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"
B This question is the most open-ended and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.
A 42-yr-old patient is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.
D Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.
When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. b. dehydration. c. elevated total serum cholesterol. d. cobalamin (vitamin B12) deficiency.
D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.
An older patient reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation a. bin the mid-afternoon. b. after eating breakfast. c. right after getting up in the morning. d. immediately before the first daily meal.
b The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes.
A 58-yr-old patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a pitcher of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with a wet cloth
A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate.
To palpate the liver during a head-to-toe physical assessment, the nurse a. places one hand on the patient's back and presses upward and inward with the other hand below the patient's right costal margin. b. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. c. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt. d. places one hand under the patient's lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.
A The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.
When caring for the patient with heart failure, the nurse knows that which gastrointestinal process is most dependent on cardiac output and may affect the patient's nutritional status? Ingestion Digestion Absorption Elimination
Absorption Substances that interface with the absorptive surfaces of the gastrointestinal tract (primarily in the small intestine) diffuse across the intestinal membranes into intestinal capillaries and are then carried to other parts of the body for use in energy production. The cardiac output provides the blood flow for this absorption of nutrients to occur.
The nurse is reviewing the home medication list for a patient admitted with suspected hepatic failure. Which medication reviewed by the nurse could cause hepatotoxicity? Digoxin Nitroglycerin Ciprofloxacin Acetaminophen
Acetaminophen Many chemicals and drugs are potentially hepatotoxic and result in significant patient harm unless monitored closely. For example, chronic high doses of acetaminophen and nonsteroidal antiinflammatory drugs may be hepatotoxic.
After assisting with a needle biopsy of the liver at a patient's bedside, the nurse should a. put pressure on the biopsy site using a sandbag. b. elevate the head of the bed to facilitate breathing. c. place the patient on the right side with the bed flat. d. check the patient's postbiopsy coagulation studies
C After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.
A patient with abdominal pain is being prepared for surgery to make an incision into the common bile duct to remove stones. What procedure will the nurse prepare the patient for? Colectomy Cholecystectomy Choledocholithotomy Choledochojejunostomy
Choledocholithotomy A choledocholithotomy is an opening into the common bile duct for the removal of stones. A colectomy is the removal of the colon. The cholecystectomy is the removal of the gallbladder. The choledochojejunostomy is an opening between the common bile duct and jejunum.
The nurse receives the following information about a 51-yr-old female patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to both shellfish and iodine in the past. d. The patient declined to drink the prescribed polyethylene glycol (GoLYTELY).
D If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.
The nurse should recognize that the liver performs which functions (select all that apply.)? Bile storage Detoxification Protein metabolism Steroid metabolism Red blood cell (RBC) destruction
Detoxification Protein metabolism Steroid metabolism Red blood cell (RBC) destruction The liver performs multiple major functions that aid in the maintenance of homeostasis. These include metabolism of proteins and steroids as well as detoxification of drugs and metabolic waste products. The Kupffer cells of the liver participate in the breakdown of old RBCs. The liver produces bile, but storage occurs in the gallbladder.
A patient is scheduled for surgery with general anesthesia in 1 hour and is observed with a moist but empty water glass in his hand. Which assessment finding may indicate that the patient drank a glass of water? Easily heard, loud gurgling in abdomen High-pitched, hollow sounds in abdomen Tenderness in left upper quadrant upon palpation Flat abdomen without movement upon inspection
Easily heard, loud gurgling in abdomen If the patient drank water on an empty stomach, gurgling can be assessed without a stethoscope or assessed with auscultation. High-pitched, hollow sounds are tympanic and indicate an empty cavity. A flat abdomen and tenderness do not indicate that the patient drank a glass of water.
The nurse is preparing a patient for a capsule endoscopy. What should the nurse ensure is included in the preparation? Ensure the patient understands the required bowel preparation. Have the patient return to the procedure room for removal of the capsule. Teach the patient to maintain a clear liquid diet throughout the procedure. Explain to the patient that conscious sedation will be used during capsule placement.
Ensure the patient understands the required bowel preparation. A capsule endoscopy study involves the patient performing a bowel prep to cleanse the bowel before swallowing the capsule. The patient will be on a clear liquid diet for 1 to 2 days before the procedure and will remain NPO for 4 to 6 hours after swallowing the capsule. The capsule is disposable and will pass naturally with the bowel movement, although the monitoring device will need to be removed.
A patient is suspected of having acute pancreatitis after presenting to the emergency department with severe abdominal pain. Which laboratory result would best indicate the presence of acute pancreatitis? Gastric pH of 1.4 Blood glucose of 104 Serum amylase of 420 U/L Serum potassium of 3.5 mEq/L
Serum amylase of 420 U/L Elevated serum amylase levels indicate early pancreatic dysfunction and are used to diagnose acute pancreatitis. The normal serum amylase levels range from 28 to 85 U/L. Serum lipase levels stay elevated longer than serum amylase in acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.
An older adult patient is seen in the primary care provider's office for a well check complains of difficulty swallowing. What common effect of aging should the nurse assess for as a possible cause? Anosmia Xerostomia Hypochlorhydria Salivary gland tumor
Xerostomia Xerostomia (decreased saliva production), or dry mouth, affects many older adults and may be associated with difficulty swallowing (dysphagia). Anosmia is loss of sense of smell. Hypochlorhydria, a decrease in stomach acid, does not affect swallowing. Salivary gland tumors are not common.
An older adult patient reports difficulty swallowing. Which age-related change does the nurse teach the patient about? Xerostomia Esophageal cancer Decreased taste buds Thinner abdominal wall
Xerostomia Xerostomia, decreased volume of saliva, leads to dry oral mucosa and dysphagia. Esophageal cancer is not an age-related change. Decreased taste buds and a thinner abdominal wall do not contribute to difficulty swallowing.
The nurse will plan to monitor a patient with an obstructed common bile duct for a. melena. b. steatorrhea. c. decreased serum cholesterol level. d. increased serum indirect bilirubin level.
B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.
Inspection of an older patient's mouth reveals the presence of white, curd-like lesions on the patient's tongue. What does the nurse recognize is the most likely etiology for this abnormal assessment finding? Herpesvirus Candida albicans Vitamin deficiency Irritation from ill-fitting dentures
Candida albicans White, curd-like lesions surrounded by erythematous mucosa are associated with oral candidiasis. Herpesvirus causes benign vesicular lesions in the mouth. Vitamin deficiencies may cause a reddened, ulcerated, swollen tongue. Irritation from ill-fitting dentures will cause friable, edematous, painful, bleeding gingivae.
Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds
c Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally
Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? a. Decreased appetite b. Unintended weight loss c. Difficulty chewing food d. Complaints of indigestion
B Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight
A patient has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.4°F. d. The apical pulse is 100 beats/minute
C A temperature elevation may indicate that an acute perforation has occurred. The other assessment data are normal immediately after the procedure.
A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.
A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.
While interviewing a young adult patient, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). The nurse will plan to assess the patient's knowledge about a. preventing noninfectious hepatitis. b. treating inflammatory bowel disease. c. risk for developing colorectal cancer. d. using antacids and proton pump inhibitors.
C FAP is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP.
A 30-yr-old male patient with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding is important to report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/minute in each quadrant d. Aortic pulsations visible in the epigastric area
B Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. The other findings are within normal range for the physical assessment.
Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I use acetaminophen (Tylenol) every 4 hours for back pain." d. "I need to take an antacid for indigestion several times a week"
C Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse but do not indicate a need for patient education.
The nurse is assessing a patient admitted with a possible bowel obstruction. Which assessment finding would be expected in this patient? Tympany to abdominal percussion Aortic pulsation visible in epigastric region High-pitched sounds on abdominal auscultation Liver border palpable 1 cm below the right costal margin
High-pitched sounds on abdominal auscultation The bowel sounds are higher pitched (rushes and tinkling) when the intestines are under tension, as in intestinal obstruction. Bowel sounds may also be diminished or absent with an intestinal obstruction. Normal findings include aortic pulsations on inspection and tympany with percussion, and the liver may be palpable 1 to 2 cm along the right costal margin.
