Chapter 20 CP

The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the

costovertebral angle. Kidney tenderness is best assessed at the costovertebral angle.

While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tingling sounds throughout the distended abdomen. The nurse should refer the client to a physician for possible

intestinal obstruction. High-pitched tinkling and rushes of high-pitched sounds with abdominal cramping usually indicate obstruction.

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

right lower quadrant. The appendix is located in the right lower quadrant.

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

usually difficult to localize Visceral pain occurs when hollow abdominal organs, such as the intestines, become distended or contract forcefully, or when the capsules of solid organs such as the liver and spleen are stretched. Poorly defined or localized and intermittently timed, this type of pain is often characterized as dull, aching, burning, cramping, or colicky.

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. Kidney tenderness is assessed posteriorly. The Blumberg assesses for rebound tenderness and the Murphy test is for inflammation of the gallbladder.

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 gallbladder is located in the right upper quadrant of the abdomen. When it is inflamed (cholecystitis), performing the Murphy's sign will cause the client to hold the breath (inspiratory arrest). The Obturator & Psoas tests are to determine if the appendix is inflamed. Rovsing's sign test for rebound tenderness which may indicate peritoneal irritation.

During the abdominal examination, a nurse supports the client's right knee and ankle. The nurse flexes the client's hip and rotates the leg externally and internally. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign?

Obturator The test indicates a positive obturator sign, which is performed to assess for appendicitis. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Murphy's sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.

A client complains of abdominal pain that is worsened with alcohol ingestion. The nurse should suspect which of the following as the underlying cause?

Pancreatitis Pancreatitis is worsened with alcohol ingestion. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Gastroesophageal reflux is worsened when supine.

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 spleen is located in the left upper quadrant. The gallbladder, liver, and head of the pancreas are located in the right upper quadrant.

The nurse percusses the lowest interface in the left anterior axillary line, asks the client to take a deep breath, and percusses again. The nurse is assessing for which of the following?

Splenic percussion sign A change in the percussion note from tympany to dullness on inspiration in this location suggests splenic enlargement. The given procedure is the correct technique for assessing for a positive splenic percussion sign, not kidney tenderness, liver palpation, or

A mother is worried about her teenage child's weight. The teenager weighs 80 kg (176 lbs). What can the nurse teach the mother about her child's eating habits? Select all that apply.

• Supply only healthy foods in the house • Supply nutritional information to the child • Educate the family about the poor nutritional value of fast food Teenagers assume control of their eating and may reject family values. The only control parents may have is over what food is in the house, although they should still supply nutritional information to their children. Fast food is high in fat, calories, and salt and has little fiber. Teenagers require 2,200 calories per day.

A 22-year-old law student comes to the office complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs, but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank around 14 drinks. Examination shows a young man appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending. What etiology of abdominal pain is most likely causing his symptoms? management, and bowel rest.

Acute pancreatitis Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates into the back. There is often a history of long-standing gallbladder disease or recent alcohol ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump inhibitors can also cause pancreatitis in people without these other risk factors. Treatment includes hydration, pain

The client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for?

Acute pancreatitis With acute pancreatitis, epigastric pain may radiate to the back or other parts of the abdomen; it may be poorly localized.

Mr. Patel, 64 years old, was told by another care provider that his liver was enlarged. Although he is a lifelong smoker with a history of emphysema, the client has never used drugs or alcohol, nor does he have any knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 cm below the costal arch. Which of the following would the examiner do next?

Determine liver span by percussion. A liver edge palpable this far below the costal arch should not be ignored. Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has developed emphysema with flattening of the diaphragms. This pushes a normal sized liver below the costal arch so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall until dullness is heard. A measurement is then made between this point and lower border of the liver to determine its span. Percussion is the only way to assess liver size on examination, and in this case saved the client much inconvenience and expense.

During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following would be most appropriate?

Document the position of the liver. The liver is located below the diaphragm in the right upper quadrant of the abdomen, extending just below the right costal margin, where it may be palpated. The findings are considered normal and the client would not need a referral for medical follow-up. The exam detects the liver, not the spleen, which would be on the left side. There are no data to support the need for assessing the client's urinary output.

Mr. Kruger, 84 years old, presents with a smooth lower abdominal mass in the midline, which is minimally tender. There is dullness to percussion up to 6 cm above the symphysis pubis. What does this most likely represent?

Enlarged bladder It is possible that this represents a sigmoid colon mass, but this is less likely than an enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently cause partial urinary obstruction with bladder enlargement. If the mass resolves with catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A hernia would most likely not be dull to percussion. Midline abdominal wall tumours of this size would be unusual but could be discerned by having the client tense his abdominal muscles.

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 should flex the client's legs by placing a pillow under the knees. This helps the abdominal muscles to relax and facilitates proper assessment. Raising the client's arms above the head or folding them behind the head may tense the abdominal muscles. Placing a pillow under the client's head or providing privacy does not help in relaxing the abdominal muscles; however, these measures will provide comfort and relaxation to the client.

The nurse is percussing a client's liver and is assessing liver descent. The nurse would have the client do which of the following?

Hold his or her breath Breathe deeply To assess descent of the liver, the nurse would ask the client to take a deep breath in and hold it. Coughing, breathing deeply, or performing the Valsalva maneuver would not be appropriate.

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 Peritonitis is assessed with Blumberg sign. Kidney pain is assessed that CVA. Appendicitis is assessed with the iliopsoas muscle test.

A 77-year-old retired bus driver presents at his wife's request to the clinic for a physical examination. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for more than 40 years. He denies any tobacco or drug use and has not drunk alcohol since getting married. His parents both died of cancer in their 60s. On examination his vital signs are in expected ranges. His head, cardiac, and pulmonary examinations are unremarkable. Abdominal examination reveals normal bowel sounds. Results of palpation of the liver are abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination?

Irregular, large liver With his past history of colon cancer and recent weight loss and fatigue, a relapse of his colon cancer would be expected. Colon cancer usually metastasizes to the liver, creating hard, irregular nodules, which can sometimes be palpated on examination. A smooth large liver that is tender is often seen in hepatitis.

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 Although colon cancer should be a consideration, these symptoms are intermittent and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely, especially given that she is a young woman. This very common condition can be triggered by certain foods and stress.

A nurse performs percussion by placing the left hand flat against the client's lower rib cage and striking it with the ulnar side of the right fist. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?

Liver Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage and striking it with the ulnar side of the right fist. The costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a kidney problem such as infection (pyelonephritis), renal calculi, or hydronephrosis. Percussion of the spleen begins in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness. The gall bladder is not percussed.

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

Murphy sign A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.

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 The pole of the right kidney, the ascending colon, and the liver are all present in the RUQ. The pancreas, descending colon, sigmoid colon, spleen, and inguinal ligament are not.

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 The appendix is located in the right lower quadrant. If the client has appendicitis, pressing deeply in this location with a sudden release of pressure will elicit a sharp, stabbing pain, which is called "rebound tenderness."

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

Right side-lying Having the client lie on the right side may facilitate splenic palpation by moving the spleen downward and forward. Alternatively, the client may be positioned supine.

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? biochemical used in the digestion process.

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

A nurse performs light palpation of the abdomen and feels a prominent, nontender, pulsating mass above the umbilicus that measures approximately 6 cm. What is an appropriate action by the nurse?

Stop the palpation and notify the health care provider A pulsating abdominal mass may indicate the presence of an abdominal aortic aneurysm. An aneurysm is an area within a vessel where the wall of the vessel becomes weak, engorged with blood, and may rupture. The nurse should stop palpating immediately and notify the health care provider. This client may need to go to surgery for repair of the aneurysm. All other options are not safe or indicated for this client at this time.

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 Bladder disorders may cause suprapubic pain

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 pain from a kidney stone causes dramatic, severe, colicky pain at the costovertebral angle that radiates across the flank and down into the groin

The colon originates in this abdominal area:

right lower quadrant. The colon, or large intestine, has a wider diameter than the small intestine (approximately 6.0 cm) and is approximately 1.4 m long. It originates in the RLQ, where it attaches to the small intestine at the ileocecal valve.

To promote relaxation of the client's abdominal muscles, which of the following would be most appropriate for the nurse to do?

Place a pillow under both of the client's knees. Placing a pillow under the client's knees provides slight flexion, which helps to relax the abdominal muscles. Having the client breathe through the mouth and take slow deep breaths promotes overall relaxation. A warm blanket prevents chilling. The nurse would inform the client that painful areas will be assessed last and would assure the client that he or she will be forewarned about examining these areas.

The nurse is preparing to palpate the client's spleen. What should the nurse instruct the client to do?

Take a deep breath and exhale The client should be lying on his back and the nurse should ask the client to take a deep breath an exhale so that palpation can occur.

Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?

Tympany that changes location with client position A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float, so dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany that changes location with client position ("shifting dullness") would support the presence of ascites. A fluid wave and edema would support this diagnosis as well.

Some changes that appear on the skin of the abdomen as a result of pregnancy are what?

• Linea nigra • Everted umbilicus • Striae A darkly pigmented line, the linea nigra, appears in the midline of the anterior abdomen from pubis to umbilicus in many pregnant women. Near the end of pregnancy, the umbilicus may become everted, and striae (stretch marks) may develop on the skin of the abdomen. Hemorrhoids occur inside the rectum or anus.

A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining whether this client is truly experiencing an alteration in bowel pattern?

"How many times a day are you having a bowel movement?" Diarrhea is defined as frequency of bowel movements producing unformed or liquid stools. To determine whether the client is truly experiencing diarrhea, the nurse should ask about how many times a day the client is having a bowel movement. The other important question is how many times a day does the client normally have a bowel movement. The consistency will not tell the nurse whether this is normal or abnormal. Asking about food intake will give information about whether the client has tried to treat the problem

A client asks a nurse how she can decrease her risk of gallbladder cancer. Which statement by the nurse is appropriate?

"A history of gallstones is the most common risk factor." Gallbladder cancer and gallstones (cholelithiasis) vary together in prevalence, making gallstones the most common risk factor. Women are affected at least twice as often as men with gallbladder cancer. Neither cigarette smoking nor alcohol intake is a risk factor.

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.

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

Absent

A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following?

Absent Absent bowel sound may be associated with peritonitis, which would occur with a ruptured appendix. The bowel sounds would not be normal. Hypoactive bowel sounds indicate diminished bowel motility, such as from surgery or late bowel obstruction. Hyperactive bowel sounds indicate increased bowel motility, such as with diarrhea, gastroenteritis, or early bowel obstruction.

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 Asking the client to raise the head off the bed will help the nurse to determine the location of the mass. A mass within the abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is obscured. Palpation and percussion should come after inspection is completed. Coughing will not assist the nurse with assessment of the abdominal mass.

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

At the symphysis pubis The urinary bladder is located behind the symphysis pubis and rises above it when distended. The nurse would begin at the symphysis pubis and move upward and outward to estimate bladder borders.

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 should document that the bowel sounds are normal. Twenty bowel sounds in a minute is not hyperactive, hypoactive, or inconsistent.

Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect?

Cholecystitis A positive Murphy's signs is associated with acute cholecystitis. Tests for shifting dullness and fluid wave would help to identify ascites. Rebound tenderness, a positive Rovsing's sign, psoas sign, obturator sign, and positive hypersensitivity test would be associated with appendicitis. Splenomegaly would be noted with percussion and palpation.

The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location?

Deep epigastrium to the left of midline To palpate the aorta, the nurse would palpate deeply in the epigastrium, slightly to the left of midline. The pregnant uterus may be palpated above the level of the symphysis pubis in the midline. A filled bladder may be palpated in the abdomen above the symphysis pubis.

The nurse understands that the liver does what?

Produces clotting factors The liver produces clotting factors. The pancreas secretes insulin, amylase and lipase.

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the

left upper quadrant.

The nurse assesses an adult male client's abdomen and observes diminished abdominal respiration. The nurse determines that the client should be further assessed for

peritoneal irritation. Diminished abdominal respiration or change to thoracic breathing in male clients may reflect peritoneal irritation.

For a 60 year old client who is deemed to be average risk for colorectal cancer, the nurse should provide which of the following instructions?

• Have a fecal occult blood test done annually. • Schedule a flexible sigmoidoscopy every 5 years. • Follow an every 10-year colonoscopy schedule. The screening for a person of average risk for colorectal cancer is an annual fecal occult blood test, flexible sigmoidoscopy every 5 years, and colonoscopy every 10 years. A colonoscopy every 3 years would be appropriate for the patient with an increased risk of colorectal cancer. A double contrast barium enema for a person of average risk should be every 5 years and not every 2 years.