Chapter 23 Assessing the Abdomen
Internal adhesions from previous surgery
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? Intestinal obstruction at the sigmoid colon Internal adhesions from previous surgery Peritonitis from a ruptured diverticulum Acute onset of appendicitis with possible rupture
viral hepatitis
A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition? alcohol hepatitis viral hepatitis intrahepatic jaundice toxic liver damage
measure abdominal girth
A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement? Palpate the abdomen Perform percussion for tympany Measure abdominal girth Auscultate for bowel sounds
absent
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 Hyperactive Erratic Hypoactive
linea alba
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? Transverse abdominis Internal abdominal oblique Peritoneum Linea alba
h pylori
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 Escherichia coli Staphylococcus aureus Streptococcus pyogenes
Higher fat-to-lean muscle ratio Older adult clients are especially at risk for potential complications with diarrhea, such as fluid volume deficit, dehydration, electrolyte, and acid-base imbalances, because they have a higher fat-to-lean muscle ratio. because they are fat!
A nurse is working with an older client who has had diarrhea for the past week and is dehydrated. The nurse understands that older clients are especially at risk for potential complications with diarrhea due to which of the following factors? Decreased sensitivity to pain Large numbers of medications taken Tendency to have an inadequate fluid intake Higher fat-to-lean muscle ratio
"How many times have you been pregnant?"
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? "Do you have high blood pressure?" "How many times have you been pregnant?" "Are you experiencing any abdominal pain?' "Have you noticed any color change to the skin?'
diaphragm
During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should begin auscultation in the left upper quadrant. listen in each quadrant for 15 seconds. palpate the abdomen before auscultation. use the diaphragm of the stethoscope.
obturator
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? Rovsing's Murphy's Obturator Psoas
urine specimen for culture
The nurse assesses a client's indwelling urinary catheter bag and observes cloudy urine. The client also complains of lower back pain. What is the nurse's best action? Flush the catheter tubing with sterile normal saline. Record the findings as expected for a client with an indwelling catheter. Prepare to obtain a urine specimen for culture. Encourage the client to increase PO fluid intake.
appendicitis
The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? Kidney pain Inflammation of the gallbladder Appendicitis Liver engorgement
identify abdominal organs deep palpation is to identify the organs , light is to identify tenderness
The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation? identify abdominal organs detect abdominal tenderness discern muscular resistance complete a surface evaluation
internal bleeding
The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible liver disease. internal bleeding. abdominal distention. Cushing syndrome.
paralytic ileus
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 fluid and electrolyte imbalances. aortic aneurysm. paralytic ileus. gastroenteritis.
dehiscence
The nurse is performing an assessment on a client that is on postop day 2. The abdominal wound has pulled apart and the contents are spilling out. The nurse recognizes this as a what? Hernia Dehiscence Infection Abscess
deep and quick
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should palpate lightly while slowly releasing pressure. palpate deeply while quickly releasing pressure. ask the client to assume a side-lying position. perform this abdominal assessment first.
costovertebral angle. The angle found on your back made by the bottom ribs meeting at an angle
The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the left upper quadrant. costovertebral angle. external oblique angle. right upper quadrant.
Applying and releasing pressure to the abdomen
The nurse would assess for positive Blumberg sign how? Applying blunt pressure at the costovertebral angle (CVA) Having the client breathe deeply Applying and releasing pressure to the abdomen Applying blunt pressure that the midclavicular line (MCL)
deep in the upper abdomen and is not normally palpable.
The pancreas of an adult client is located posterior to the left midaxillary line and posterior to the stomach. below the diaphragm and extending below the right costal margin. high and deep under the diaphragm and can be palpated. deep in the upper abdomen and is not normally palpable.
right lower quadrant.
To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's left upper quadrant. right upper quadrant. right lower quadrant. left lower quadrant.
left upper quadrant
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the left upper quadrant. right lower quadrant. right upper quadrant. left lower quadrant.
The one where they kick up and you hold it down or they kick back while on their side.
What is psoas test?
solid retain their shape always like a liver, while hollow adjust to the contents inside like the stomach.
What is the difference between solid viscera and hollow viscera?
Place the tape measure behind the client and measure at the umbilicus
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? Inform the client that the pen mark on the abdomen should not be washed off Ask the client to be seated and relaxed when taking the measurement Ensure that the client has had a full meal before measuring the abdomen Place the tape measure behind the client and measure at the umbilicus
right upper
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? right lower left lower left upper right upper
abdominal aortic aneurysm
When you are observing the aortic pulsations and they are exaggerated, what is this potentially a sign of?
Malabsorption syndrome is characterized by stool that is typically bulky, soft, light yellow to gray, mushy, greasy or oily, sometimes frothy, and particularly foul-smelling, and it usually floats in the toilet. like diarrhea
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 Crohn disease Lactose intolerance Ulcerative colitis
energy, glucose or fat
amino acids can be metabolized into what three things?
Crohn's disease
A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? Crohn's disease Gastric ulcer Pancreatitis Gastroesophageal reflux
"How many times a day are you having a bowel movement?"
A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining if this client is truly experiencing an alteration in bowel pattern? "Have you changed your food intake this week?" "How many times a day are you having a bowel movement?" "What is the consistency of your stools??" "Do you have a bowel movement every day?"
the abdominal aorta and its major branches, which are the left and right iliac arteries
Abdominal organs are supplied with blood from what vessels?
large intestines
Where in the digestive tract is most of the water absorbed? Stomach Duodenum Large intestine Ileum
food service
Which of the following people need to be vaccinated for hepatitis A and B? Truck drivers Animal care workers Food-service workers Office personnel
occurs when the parietal peritoneum becomes inflamed, as in appendicitis and peritonitis
Describe parietal pain?
ravels, or refers, from the primary site and becomes highly localized at the distant site (Weber 481)
Describe referred pain?
10x5x2.5 T12-L3 The right kidney sits lower
Describe the size of the kidney, location according to vertebrate and which kidney is lower?
The abdominal contents are enclosed externally by the abdominal wall musculature, which includes three layers of muscle extending from the back, around the flanks, to the front. (Weber 473)
How many layers of muscle are in your abdominal area?
Place left hand on right lower rib cage, strike it with ulnar side of right fist
How should the nurse perform blunt percussion over the liver? Place left hand on right lower rib cage, strike it with radial side of right fist Place right hand on mid of the rib cage; strike it with ulnar side of left fist Place left hand on right lower rib cage, strike it with ulnar side of right fist Place right hand on mid of the rib cage; strike it with ulnar side of left fist
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 Gallbladder Liver Pancreas
small intestines
Most absorption of nutrients occurs where in the GI?
tympani that changes location with the client position
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites? Dullness that remains despite change in position Dullness centrally when the client is supine Tympany that changes location with client position Bilateral flank tympany
masses
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 gallbladder disease. cachexia. kidney trauma. masses.
fluid accumulation
On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity? Bleeding Inflammation Obstruction Fluid accumulation
borborygmus
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 Absent Erratic Hypoactive
Older adult clients are prone to UTIs because the activity of protective bacteria in the urinary tract declines with age. (Weber 479)
Why are old people more prone to UTI's
murphy sign
You are assessing a patient for acute cholecystitis. What sign would you assess for? Psoas sign Cutaneous hyperesthesia Obstipation sign Murphy sign
including glucose storage, formation of blood plasma proteins and clotting factors, urea synthesis, cholesterol production, bile formation, destruction of red blood cells, storage of iron and vitamins, and detoxification. (Weber 474)
What are the functions of the liver?
The outermost layer is the external abdominal oblique, the middle layer is the internal abdominal oblique, and the innermost layer is the transverse abdominis (Weber 473) (transfers is deepest)
What are the three layers and what order.
Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination. (Weber 484)
What do you do ask the patient to do before you perform an abdominal assessment?
small pillow -centimeter ruler -stethoscope -marking pen
What equipment do you need for an abdominal assessment?
Cushing's syndrome
What if you spot dark bluish-pink striae?
When you curl a finger under the rib cage right by the liver and then ask the patient to take a deep breath. If there is pain then that is a gallbladder or liver problem.
What is Murphy's sign?
stomach growling
What is borborygmus?
Indigestion
What is pyrosis?
The spleen functions primarily to filter the blood of cellular debris, to digest microorganisms, and to return the breakdown products to the liver. (Weber 475)
spleen function?
True
true or false, liver size decreases after age 50?
rebound tenderness
what is a blumberg sign?
Inflammation of the membrane lining the abdominal wall and covering the abdominal organs.
what is peritonitis?
