chapter 16

Which change in auscultation of bowel sounds should the nurse recognize as most diagnostic of an intestinal obstruction?

An increase in the pitch

A 66-year-old client has presented to the clinic complaining of recurrent constipation and the passage of thin, pencil-like stools. What diagnostic test should the nurse prioritize?

Fecal occult blood test (FOBT)

The linea alba is located where?

Middle of the ventral abdominal wall

You are assessing a patient for acute cholecystitis. What sign would you assess for?

Murphy sign

The nurse correctly identifies the gallbladder is located where?

RUQ

Which nursing diagnosis is most appropriate for an elderly client with poor dentition?

Risk for Imbalanced Nutrition: Less Than Body Requirements

A nurse performs light palpation of the abdomen and feels a prominent, non-tender, pulsating mass above the umbilicus that measures approximately six (6) centimeters. What is an appropriate action by the nurse?

Stop the palpation and notify the health care provider

A 27-year-old policewoman comes to the clinic with severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate, but she has no burning on the outside. She has had no frequency or urgency with urination, but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative, and her urine analysis shows red blood cells. What type of urinary tract pain is she most likely to have?

Ureteral pain (from a kidney stone)

A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen?

absent

Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause?

an enlarged liver felt during palpation

A 55-year-old African American man presents at the clinic with a chief complaint of "indigestion." The patient tells the nurse, "It usually happens after I do things like mowing the lawn or doing other yard work." What should the nurse suspect?

angina

An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What might this client's medical diagnosis be?

appendicitis

Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?

appendicitis

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what?

appendicitis

The nurse would assess for positive Blumberg sign how?

applying and releasing pressure on the abdomen

A nurse inspects a client's abdomen and notices that a bulge is present in the right lower quadrant. How should the nurse further assess this finding using inspection?

ask the client to raise the head off the bed

A client's bladder is found to be distended. At which location would the nurse begin palpating?

at the symphysis pubis

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?

before i examine the painful area, i will let you know with plenty of time

Jim is a 60-year-old man who presents with vomiting. He denies any blood in his emesis, which has been present for 2 days. He does note a dark granular substance resembling the coffee left in the filter after brewing. What should the nurse suspect?

bleeding from a peptic ulcer

When palpating a client's liver, the nurse feels a firm edge. What would this indicate to the nurse?

cirrhosis of the liver

A college student presents to the health care clinic with reports no bowel movement for four (4) days, bloating, and generalized abdominal discomfort. She states she has not been eating and drinking correctly and is stressed because she has a final exam in two (2) days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants, tenderness in the left lower quadrant with a few small round, firm masses. Rovsing's sign and the Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client?

constipation related to fluid intake

The nurse assess for kidney tenderness at what location?

costovertebral angle

Mrs. Wells presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that Mrs. Wells has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain?

dyspepsia

When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?

family history, dietary habits

Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?

flex legs by putting pillow under knees

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

food service workers

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved?

gallbladder

A daycare worker presents to the office with jaundice. She denies IV drug use, blood transfusion, and travel, and has not been sexually active for the past 10 months. Which type of hepatitis is most likely?

hepatitis A

A nurse observes 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

Nursing students are learning how to identify different areas of the abdomen. What is the lower middle area called

hypogastric

The nurse as elicited a positive Murphy sign. The knows this is indicates what?

inflammation of the gallbladder

A client presents to the emergency department with reports of new onset of abdominal pain for the past three (3) days. The client states there is also a pulling feeling on the right side. Upon examination the nurse notices a 5cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process?

internal adhesions from previous surgery

A 21-year-old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology?

irritable bowel syndrom

Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely?

irritable bowel syndrome

A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following?

it is a normal sized liver

A client reports severe pain in the left lower quadrant of three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history?

left lower quadrant is palpated last

A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10-year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time?

listen with the bell of the stethoscope for vascular sounds

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

A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?

murphy's

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 patient's face for signs of discomfort

While auscultating a client's abdomen, the student notes abnormal bowel sounds. The student's nursing preceptor asks the student to describe the sounds. The student describes them as high-pitched, rushing sounds. The nursing preceptor would know that these sounds indicate what?

partial intestinal obstruction

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse interprets this as which of the following?

positive rovsing's sign

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location?

right lower quadrant

A nurse is preparing to palpate a client's spleen. Which position would the nurse use to facilitate palpation?

right side lying

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant?

right upper

During an assessment, the patient describes vomiting moderate amounts that "smell like poop." The nurse might suspect

small bowel obstruction

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant?

spleen

The nurse understands this abdominal organ is responsible for storing red blood cells and platelets.

spleen

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

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus?

stop palpating and get medical assistance

A 52-year-old secretary comes to the office complaining about accidentally leaking urine when she coughs or sneezes. She says this has been going on for about 1 year. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is significant for four spontaneous vaginal deliveries. She is married with four children. She denies alcohol, tobacco, or drug use. Pelvic examination reveals some atrophic vaginal tissue but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable. Which type of urinary incontinence does she have?

stress inincontinence

When inspecting the abdomen, which of the following client positions facilitates correct examination technique?

supine with arms at sides or across chest

Your patient has a bladder disorder. Where would you expect the pain to be?

suprapubic

Which of the following statements provides the most accurate guide to the assessment of the gallbladder?

the gallbladder is deep to the liver and cannot normally be distinguished

The nurse is admitting a new client to the floor and asks if the client has any dizziness. Why does the nurse do this?

to check for possible dehydration

Rovsing's sign is a test of referred rebound tenderness in appendicitis.

true

When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach

true

Linda is a 29-year-old who had excruciating pain that started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely given this presentation?

ureteral stone

Mrs. LaFarge, 60 years old, presents with urinary incontinence. She cannot get to the bathroom quickly enough when she senses the need to urinate. She has normal mobility. Which of the following is most likely?

urge incontinence

Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is

usually difficult to localize

When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication?

vitamin supplement with iron

A client reports a decrease in appetite over the past month. What additional assessment should a nurse gather in relation to this data? Select all that apply.

weight, food intake

What can cause bladder distention? (Mark all that apply.)

• Medications • Stroke • Multiple sclerosis