Chapter 23: Assessing the Abdomen PREP U

The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation?

identify abdominal organs

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?"

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 his bladder.

During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document this finding?

associated manifestations The nurse should document this finding in the associated manifestations section because this is a report on the experience of other symptoms associated with abdominal pain. In relieving factors, the nurse explores factors that aggravate or relieve the pain. In characteristic symptoms, the nurse should ask the client to describe the pain in his or her own words. Onset refers to when the abdominal pain started.

The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area?

auscultation

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. Vomiting with blood (hematemesis) is seen with esophageal varies or duodenal ulcers.

A nurse suspects that a client has gastroesophageal reflux disease (GERD). Which risk factors must be present for the nurse to confirm this? Select all that apply.

taking multiple medications hiatal hernia body mass index greater than 30 Risk factors for gastroesophygeal reflux disease (GERD) include obesity, side effects of various medications, and a hiatal hernia. Alcohol intake is not a risk factor for GERD but can aggravate heartburn, a rising pain that burns or causes discomfort weekly or more often. Passing excess flatus is commonly associated with aerophagia, lactase deficiency, or irritable bowel syndrome.

The nurse suspects an abdominal aortic aneurysm when what is assessed?

Abdominal bruit

Which of the following acute abdominal symptoms could be life threatening?

Abdominal 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

During deep palpation of the abdomen, a client experiences right lower quadrant rebound tenderness. The nurse should conduct which additional assessments? (Select all that apply.)

Assess for the Obturator sign. Palpate for the Rovsing's sign. Assess for a Psoas sign.

The nurse is assessing a client in the emergency department. The client was involved in a motor vehicle accident and is experiencing left upper abdominal pain. The nurse should intervene when another health care provider does which of the following?

Attempts to palpate the spleen

A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend?

Avoid excessive alcohol intake

An older client presents with symptoms of pain on urinating. The nurse recognizes that older adults are at increased risk for urinary tract infections for which of the following reasons?

Decreased activity of protective bacteria in the urinary tract

The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client 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

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

A client complains of a sudden onset of pain in the back. On questioning the client further, the nurse learns that the cause of the pain is acute pancreatitis. The nurse recognizes that this type of pain is which of the following?

Referred pain

Which of the following is consistent with obturator sign?

Right hypogastric pain with the right hip and knee flexed, and the hip internally rotated

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

Rovsing sign Cutaneous hyperesthesia psoas sign

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

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 nurse is assessing an older adult client admitted to the hospital with acute diverticulitis. No bowel sounds are heard for 5 minutes and the abdomen is firm and rigid. What complication would the nurse suspect?

peritonitis

To palpate the spleen of an adult client, the nurse should

place the right hand below the left costal margin.

A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says

"I can decrease the constipation if I eat foods high in fiber and drink water."

The nurse finds the client's abdomen to be distended. The nurse recognize distention may be caused by what? Select all that apply.

-Gas-Fluid-Feces-Fetus

Your client 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 client?

-malabsorption syndrome 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.

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?

Abdominal aortic aneurysm

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 should find that bowel sounds are absent in a client with paralytic ileus. Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds. Hyperactive bowel sounds may be caused by diarrhea, gastroenteritis, and early bowel obstruction. Hypoactive bowel sounds may be due to surgery or late bowel obstruction. Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling." Erratic is not a type of bowel sound.

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

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?

Fluid accumulation

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

Food-service workers

The nurse assess for kidney tenderness at what location?

Costovertebral angle

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

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

Gastric ulcer

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 Explanation: Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucous, on occasion the H. pylori disrupt the mucous lining and inflame the organ lining.

The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates?

Inflammation of the gallbladder

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

Where in the digestive tract is most of the water absorbed?

Large intestine Any food particles not absorbed by the small intestine pass into the large intestine, where a few electrolytes and water are further absorbed.

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

A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement?

Measure abdominal girth

Where is the linea alba located?

Middle of the ventral abdominal wall

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

Murphy sign

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

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 nurse needs to assess the abdomen of a hospitalized client post gastrointestinal surgery. Place the following assessment steps in order as the nurse enters the client's room.

Perform a general survey of safety hazards. Inspect the abdomen .Auscultate all four quadrants. Palpate for tenderness. Document the findings.

The nurse is teaching a group of new nurses about gastrointestinal changes associated with age. The nurse should provide additional education when a new nurse lists which of the following changes? Select all that apply.

Peristalsis increases with age Older adults are more sensitive to abdominal pain

How should the nurse perform blunt percussion over the liver?

Place left hand on right lower rib cage, strike it with ulnar side of right fist

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?

Place the tape measure behind the client and measure at the umbilicus

The nurse is assessing a client with a bladder disorder. Where would the nurse 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 from the liver clinically. Explanation: Because the gallbladder is deep to the liver, it is normally not amenable to direct examination by auscultation, palpation, or percussion. This does not mean, however, that cholecystitis and cholelithiasis cannot be assessed for a thorough history. The gallbladder and the spleen are not proximate.

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 assessing the abdomen of a client. While percussing the abdomen, what normal sound does the nurse expect to hear?

Tympany

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

The abdominal contents are enclosed externally by the abdominal wall musculature—three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external

abdominal oblique.

For a client who is deemed to be an average risk for colorectal cancer, the nurse should review which screening test(s) according to recommendations from the American Cancer Society (2018)? Select all that apply.

colonoscopy flexible sigmoidoscopy fecal occult blood test

The pancreas of an adult client is located

deep in the upper abdomen and is not normally palpable.

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 Rushes of high-pitched sounds coinciding with an abdominal cramp indicate intestinal obstruction. Bowel sounds are increased in diarrhea. Bowel sounds may be decreased and then absent in ileus and peritonitis.

The sigmoid colon is located in this area of the abdomen: the

left lower quadrant.

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

left upper quadrant.

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

To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should

raise the client's right leg from the hip.

The nurse working in a clinic is assessing a 33-year-old male client. Click to highlight the findings that will require follow-up. The client reports recent increase in lethargy, and shortness of breath with activity . The nurse performs a comprehensive assessment. Findings reveal pale, cool skin; weak pulses bilaterally ; and delayed capillary refill time . Vital signs include: temperature, 97.7°F (36.5°C); heart rate, 95 beats/min; blood pressure, 110/65 mm Hg; respiratory rate, 16 breaths/min ; oxygen saturation, 93% on room air . The client denies difficulty voiding but reports dark, tarry stools for the past month .

recent increase in lethargy, and shortness of breath with activity pale, cool skin; weak pulses bilaterally delayed capillary refill time

To palpate 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

Diagnostic tests completed validate that a client has an obstruction of the ascending and transverse colon. Where should the nurse assess for bowel sounds around the obstruction?

right upper quadran tThe right upper quadrant is used to assess for the ascending and transverse colon. The left upper quadrant is used to assess the transverse and descending colon. The left lower quadrant is used to assess the descending and sigmoid colon. The right lower quadrant is used to assess the ascending colon.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible

umbilical hernia

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.

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 Visceral pain in the right upper quadrant often suggests liver distension and may be related to alcohol hepatitis. Parietal pain originates from inflammation in the parietal peritoneum also known as peritonitis. Referred pain is felt in the more distant sites, which are innervated at approximately the same spinal levels as the body structure that is inflamed. Right upper quadrant pain is not related to or caused by any problems of the musculoskeletal system.