Chapter 20: Abdominal Assessment
The peritoneum is a serous membrane that contains which of the following?
A parietal layer
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?
Abdominal aortic aneurysm
A 26-year-old sports store manager comes to the clinic with severe right-sided abdominal pain for 12 hours. He began having a stomach ache yesterday with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 38.8° and his heart rate is 170. His bowel sounds are decreased, and he has rebound and involuntary guarding at one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain?
Acute appendicitis
A 27-year-old woman comes to the emergency department reporting severe right lower quadrant pain. Her temperature is 101.5°F (38.6°C), BP 122/80 mm Hg, pulse 95 beats/min, and respirations 22 breaths/min. What might the nurse suspect the client has?
Acute appendicitis
The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what?
Appendicitis
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
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 decrease in fluid intake
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
Why is the appearance of urine important to evaluate during an abdominal examination?
Dark urine may be from dehydration
A client is told by another care provider that his liver was enlarged. Although the client is a lifelong smoker with a history of emphysema, the client has never used drugs or alcohol, nor does the client have any knowledge of liver disease. Upon examination by the nurse, a liver edge is palpable 4 cm below the costal arch. Which intervention would provide the most relevant information to determine liver status at this time?
Determine liver span by percussion.
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
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 the client's legs by placing a pillow under the knees
The nurse demonstrates the correct technique for assessing the psoas sign by which action?
Flexing the client's right hip, applying downward pressure on the right thigh
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 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
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 auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse?
Listen for a total of 5 minutes
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
Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure?
Overflow incontinence
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 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
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. How would the nurse document this finding?
Positive Rovsing's sign
The client would complain of pain in what quadrant if experiencing appendicitis?
RLQ
Which of the following is consistent with obturator sign?
Right hypogastric pain with the right hip and knee flexed, and the hip internally rotated
Which nursing diagnosis is most appropriate for an elderly client with poor dentition?
Risk for Imbalanced Nutrition: Less Than Body Requirements
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 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.
When inspecting the abdomen, which of the following client positions facilitates correct examination technique?
Supine with arms at sides or folded across chest
The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?
Suprapubic
The nurse is assessing the gastrointestinal system of an 81-year-old client. What age-related change should the nurse consider when collecting and analyzing assessment data?
The client is more vulnerable to impaired nutrition due to decreased appetite.
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 from the liver clinically.
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
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)
The nurse suspects an abdominal aortic aneurysm when what is assessed?
abdominal bruit
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
Older adults often have trouble with swallowing. What might cause this?
decreased saliva production
To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's
left lower quadrant.
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 palpating in the right upper abdominal quadrant and feels and enlarged area. The nurse recognizes that she is most likely feeling what organ?
liver
While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible
masses
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
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant?
right upper
A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?
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
When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach.
true
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
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."
A 49-year-old woman has visited the clinic with complaints of excessive flatus and bloating, symptoms that are causing her both discomfort and embarrassment. Which of the following questions should the nurse ask the client during assessment of the health problem?
"Do you find that any particular foods, like dairy, make the problem worse?"
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?"
