Chapter 16- The Gastrointestinal and Renal Systems- Coursepoints

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 get ready to examine the painful area, I will let you know in plenty of time."

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

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should

Ask the client to empty their bladder

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.

While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound?

Borborygmus

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

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 fluid intake

The nurse assess for kidney tenderness at what location?

Costovertebral angle

The nurse is caring for a client who is vomiting. When inspecting the vomitus, the nurse notes that it appears to contain coffee grounds. This would indicate what to the nurse?

Digested blood

The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant?

Dullness

A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?

Gastric ulcer

Which strategy by the nurse would best facilitate palpation of a ticklish client's abdomen?

Have client place hand on the abdomen with the nurse's hand on top.

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

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

Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure?

Incontinence overflow

While auscultating rushes of high-pitched bowel sounds a client complains of abdominal pain. What should the nurse suspect is occurring with this client?

Intestinal obstruction

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.

Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?

It is a splenic rub

A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following?

Linea alba

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Listen for at least five minutes before documenting an absence of bowel sounds.

The nurse correctly identifies the gallbladder is located where?

RUQ

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located?

Right Upper Quadrant (RUQ)

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

To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's

Right lower quadrant

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

Right upper

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

Risk for Imbalanced Nutrition: Less Than Body Requirements

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

SPLEEN

When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?

Scaphoid

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

Which of the following should a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?

Splenomegaly

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

TRUE

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

The left lower quadrant is palpated last

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

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?

Tympany

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.

A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment?

place a small pillow under the client's knees

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's

right upper quadrant.

A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of

stomach ulcers

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should

use the diaphragm of the stethoscope.