Exam4 EAQ Ch. 21

The nurse is caring for a newborn with an umbilical hernia. What should the nurse teach the parents before the infant is discharged from the health care facility? "Hernias usually resolve within a year." "Do not affix a belt or a coin at the hernia." "The hernia usually occurs with bronchitis." "The hernia is accentuated with coughing." "Ensure the infant does not strain while coughing."

"Hernias usually resolve within a year." "Do not affix a belt or a coin at the hernia." "The hernia is accentuated with coughing."

The nurse is teaching a class about assessing bowel sounds. Which statement made by a student nurse indicates the need for further teaching? "Listen to bowel sounds in all four quadrants." "It is not necessary to count the bowel sounds." "Bowel sounds may occur 5 to 30 times per minute." "Listen for 5 minutes to confirm the absence of bowel soun

"Listen to bowel sounds in all four quadrants."

Which soft, lobulated gland is located behind the stomach? Liver Spleen Pancreas Gallbladder

Pancreas The pancreas is a soft, lobulated gland located behind the stomach. It stretches obliquely across the posterior abdominal wall to the left upper quadrant. The liver fills most of the right upper quadrant and extends over to the left midclavicular line. The spleen is a soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity. It lies just under the diaphragm. The gallbladder rests under the posterior surface of the liver, just lateral to the right midclavicular line.

What is a normal finding in the assessment of a 3-year-old child? Potbelly Flat abdomen Scaphoid abdomen Protuberant abdomen

Protuberant abdomen A child younger than 4 years of age has an immature abdominal musculature. This results in a protuberant abdomen when the child is supine or standing. After the age of 4, the potbelly remains when the child is standing because of lumbar lordosis. However, the abdomen looks flat when the child is supine. A scaphoid abdomen is abnormal at any age and is indicative of malnutrition or dehydration.

What assessment finding does the nurse relate to the presence of a large ovarian cyst that is found during a patient's abdominal examination? Presence of taut glistening skin Presence of an everted umbilicus Presence of bulging flanks when supine Transmission of aortic pulsation on palpation Presence of a curve in the lower half of the abdomen

Presence of an everted umbilicus Transmission of aortic pulsation on palpation Presence of a curve in the lower half of the abdomen

The internal organs of the abdomen are called viscera. Which organs constitute the solid viscera? Liver Colon Kidneys Ovaries Stomach

Kidneys Ovaries Liver

The nurse is assessing a patient with an enlarged spleen as a nursing student watches. Which statement by the student indicates a need for more teaching? "The spleen slides out of position if enlarged." "The spleen should be continuously palpated." "The spleen may become enlarged following a trauma." "The enlarged spleen can extend into the lower quadrant."

"The spleen should be continuously palpated." An enlarged spleen has a tendency to be friable and can rupture easily with overpalpation. If the nurse suspects an enlarged spleen, he or she should refer it to the health care provider rather than overpalpating it. Trauma, leukemias, lymphomas, portal hypertension, and HIV infection can cause enlargement of the spleen. The spleen slides out of position when enlarged and can be felt with the fingertips as the nurse palpates. The spleen can grow so large that it extends into the lower quadrants.

The nurse is preparing to examine the abdomen of a patient who is supine on the examination table. What observation does the nurse associate with abdominal pain? Absolute stillness Voluntary guarding Slow, even respirations Benign facial expression

Absolute stillness "A patient who is absolutely still and resists any movement while on the examination table is in pain, most probably due to peritonitis. Voluntary guarding occurs bilaterally and is normal when the patient feels cold, tense, or ticklish. Rapid, uneven respirations are an indication of pain, whereas slow and even respirations indicate that the patient is comfortable. A patient who is not in pain will have a benign facial expression, whereas facial grimacing is an indication of pain."

While assessing a patient with abdominal distention, the nurse observes that the shape of the abdomen is like a single round curve. On palpation, the nurse detects a muscle spasm of the abdominal wall. What is the likely cause of the abdominal distention? Air Feces Tumor Ovarian cyst

Air Abdominal distention that looks like a single rounded curve and muscle spasm of the abdominal wall are classic symptoms of trapped air or gas. If the abdomen is distended only in one place it may indicate another problem, such as a buildup of feces, a tumor or an ovarian cyst, and the nurse would palpate the abdomen to find other symptoms. If feces were the cause of the localized distention, the nurse would feel a plastic-like or rope-like mass caused by feces in the intestine. An ovarian cyst would be marked by an everted umbilicus and aortic pulsation on palpation. To diagnose a tumor, the nurse may look for an enlargement of an organ on palpation of the distended abdomen.

The nurse observes rebound tenderness in the abdomen of a patient. What condition does this finding indicate? Appendicitis Gastric ulcer Pancreatitis Gastroesophageal reflux disease (GERD)

Appendicitis "Rebound tenderness is assessed when the patient reports abdominal pain. Rebound tenderness is a reliable sign of peritoneal inflammation caused by appendicitis. A dull, aching, gnawing epigastric pain triggered by food and radiating to the back or substernal area indicates gastric ulcer. GERD is a symptom of esophagitis; it can include a burning pain in the mid-epigastrium or behind the lower sternum, which radiates upward. Pancreatitis is inflammation of the pancreas, which manifests as an acute, boring mid-epigastric pain radiating to the back and sometimes to the left scapula or the flank."

What precaution does the nurse take while auscultating the abdomen of a patient? Push the stethoscope against the skin Auscultate the abdomen after palpation Auscultate using the diaphragm endpiece Begin auscultation from the left upper quadrant

Auscultate using the diaphragm endpiece

What symptoms are expected if a patient with lactose intolerance consumes milk products? Pyrosis Bloating Flatulence Constipation Abdominal pain

Bloating Flatulence Abdominal pain

The nurse elicits tenderness while palpating a patient's abdomen. Which assessment does the nurse use to confirm rebound tenderness? Murphy sign Blumberg sign Obturator test Iliopsoas muscle test

Blumberg sign "The nurse assesses the abdomen for rebound tenderness using the Blumberg sign by choosing a site away from the painful area and holding the hand perpendicular to the abdomen. The nurse then pushes down slowly and deeply, and then lifts up quickly. This makes the structures that are indented by palpation rebound suddenly. A positive response is pain on release of pressure, indicating peritoneal inflammation. Murphy sign is used to assess the inspiratory arrest in a patient with cholecystitis. The obturator test is a technique that stretches the obturator muscle. The iliopsoas muscle test is used to test for an inflamed iliopsoas muscle, which occurs with an inflamed or perforated appendix."

While assessing a 35-year-old patient, the nurse hears a vascular sound between the xiphoid process and the umbilicus. What can the nurse presume from the sound? Bruits Stenosis Borborygmus Occlusion of an artery

Bruits Vascular sounds are also called bruits. Few healthy adults younger than 40 years of age have a normal bruit originating from the celiac artery. It is systolic, medium to low in pitch, and heard between the xiphoid process and the umbilicus. A systolic bruit accompanied by a pulsatile blowing sound indicates stenosis or occlusion of an artery. Borborygmus is not a vascular sound but a type of hyperactive bowel sound. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

A patient is admitted with a sudden pain in the right upper quadrant (RUQ) that radiates to the right or the left scapula. The patient is also reports nausea and vomiting. On reviewing the patient's diet, the nurse learns the patient is fond of both fatty foods and alcohol. What does the nurse suspect from these symptoms and findings? Hepatitis Appendicitis Gastric ulcer Cholecystitis

Cholecystitis

While assessing a 4-year-old patient, the nurse observes the abdomen of the child has a scaphoid shape. What is the possible cause of the shape? Tumor Feces Ascites Dehydration

Dehydration "Scaphoid abdomen is a condition in which the anterior wall of the abdomen is sunken and shows a concave structure rather than a convex one. Scaphoid abdomen indicates dehydration in the patient, and the abdomen sinks due to inadequate intake of fluid. The abdomen will show localized distention rather than a scaphoid shape in the case of a tumor. Feces will cause localized distention rather than presenting a sunken shape. Ascites manifests as a single curve and an everted umbilicus. "

What are the changes in the gastrointestinal system due to aging? Increased salivation Decreased liver size Decreased sense of taste Impaired drug metabolism Rapid esophageal emptying

Decreased liver size Decreased sense of taste Impaired drug metabolism

What problem does the nurse expect to find in a patient with dysphagia? Difficulty in swallowing Loss of weight and appetite Intolerance to milk products Burning sensation in the esophagus

Difficulty in swallowing

The nurse places the stethoscope over the xiphoid process while lightly stroking the skin with one finger up the midclavicular line from the right lower quadrant (RLQ). Which test is the nurse performing in the patient? Detecting liver span Doing a scratch test Detecting splenic dullness Detecting voluntary guarding

Doing a scratch test The scratch test is a traditional technique to detect the lower border of the liver. The nurse places the stethoscope over the xiphoid process while lightly stroking the skin with one finger up the midclavicular line from the right left quadrant (RLQ), parallel to the liver border. As the nurse reaches the liver edge, the sound magnifies in the stethoscope. The percussion method detects the liver span. Splenic dullness is the method of detecting the spleen. Often, the stomach obscures the spleen. Voluntary guarding occurs when the person is cold, tense, or ticklish. It is bilateral, and the muscle relaxes during exhalation.

The nurse palpates a small, fatty nodule through the linea alba on the abdomen when the patient is standing. What term does the nurse use to document this finding? Diastasis recti Epigastric hernia Incisional hernia Umbilical hernia

Epigastric hernia The nurse documents the finding as epigastric hernia. It is the protrusion of the abdominal structures. Examination reveals a small, fatty nodule at the epigastrium midline, through the linea alba. Diastasis recti is the separation of the abdominal rectus muscles. A midline longitudinal ridge is revealed when intra-abdominal pressure is increased by raising patient's head while supine. An incisional hernia is a bulge near an old operative scar. This bulge is usually apparent when the patient increases the intra-abdominal pressure by a sit-up, by standing, or by the Valsalva maneuver. An umbilical hernia is the protrusion of the omentum or the intestine through a weakness or incomplete closure in the umbilical ring. It is common in premature infants and is accentuated by increased intra-abdominal pressure as with crying, coughing, vomiting, or straining.

Which condition in a patient hinders the accurate detection of liver borders? Peritonitis Gas distention Scaphoid abdomen Costovertebral angle tenderness

Gas distention Accurate detection at the lower border of the liver is confused when dullness in the liver sound is pushed up due to gas distention in the colon. This condition also occurs during pregnancy and in ascites. Peritonitis is associated with abdominal distention and is not related to detection of liver borders. In a scaphoid abdomen, the anterior abdominal wall is sunken and presents a concave shape. It indicates dehydration and is unrelated to liver border detection. Costovertebral angle tenderness helps in assessing the kidneys rather than the liver.

A patient reports a dull pain in the right upper quadrant (RUQ) of the abdomen. On further assessment, the nurse detects general malaise, anorexia, and nausea in the patient. What does the nurse suspect from these signs and symptoms? Hepatitis Pancreatitis Cholecystitis Gastroesophageal reflux disease (GERD)

Hepatitis Hepatitis is a liver disease caused by the hepatitis virus. The disease manifests as moderate, dull pain in the RUQ of the abdomen. General malaise, anorexia, and nausea are common symptoms of hepatitis. GERD is a symptom of esophagitis that includes burning pain in the mid-epigastrium or behind the lower sternum radiating upward. Cholecystitis manifests as sudden pain in the RUQ; it may radiate to the right or the left scapula. Pancreatitis is an inflammation of the pancreas, which manifests as acute, boring mid-epigastric pain radiating to the back and sometimes to the left scapula or the flank.

Which test does the nurse use to assess a patient with suspected appendicitis pain? Scratch test Fluid wave test Shifting dullness test Iliopsoas muscle test

Iliopsoas muscle test The nurse uses the iliopsoas muscle test when acute abdominal pain is suspected to be due to appendicitis. Inflammation of the iliopsoas muscle occurs with an inflamed or perforated appendix. The patient feels pain in the right lower quadrant during the test. The scratch test is a traditional technique that uses auscultation to detect the lower border of the liver. The fluid wave test and the shifting dullness test are used to determine free fluids in the peritoneal cavity.

While assessing a patient with a distended abdomen, the nurse observes marked visible peristalsis. What is the most probable cause of this finding? Ascites Hypertension Enlarged liver Intestinal obstruction

Intestinal obstruction It is normal to observe peristaltic waves that ripple slowly and obliquely across the abdomen in very thin people. The presence of marked visible peristalsis combined with a distended abdomen indicates intestinal obstruction. The patient with ascites has a distended abdomen but no visible peristaltic movement. The patient with hypertension may have marked pulsation of the aorta with widened pulse pressure. The enlarged liver is smooth and tender to palpation without marked visible peristalsis.

What are the normal features of the spleen? It lies under the diaphragm. It is a palpable visceral organ. It lies parallel to the tenth rib. It extends to the lower quadrants. It is a soft mass of lymphatic tissue.

It lies under the diaphragm. It lies parallel to the tenth rib. It is a soft mass of lymphatic tissue. The spleen lies in the posterolateral wall of the abdominal cavity, immediately under the diaphragm. It lies obliquely with its long axis behind and parallel to the tenth rib, lateral to the midaxillary line. It is about 7 cm wide and extends from the ninth to the eleventh rib. It is a soft mass of lymphatic tissue. It is a solid visceral organ that is not palpable normally. It is palpable only if it is enlarged. The spleen normally occupies the left upper quadrant. If it becomes enlarged, its lower pole moves downward and toward the midline, extending to the lower quadrants.

The nurse is preparing a patient for an abdominal examination. What are the procedures the nurse should follow? Keep the room warm. Ask the patient to be in a prone position. Ask the patient to stretch his or her knees. Ask the patient to empty his or her bladder. Cool the stethoscope endpiece before using.

Keep the room warm. Ask the patient to empty his or her bladder. "While preparing for an abdominal examination, the nurse should ask the patient to empty his or her bladder to enhance abdominal wall relaxation. The room should be kept warm to avoid chilling and tensing of abdominal muscles. The patient should be in a supine position during the examination. The knees of the patient should be bent to promote abdominal muscle relaxation. The stethoscope endpiece must be warmed to avoid abdominal tensing."

The nurse is assessing a patient who reports sudden onset of pain in the lower abdomen. What is the most probable cause of the pain? Appendicitis Cholecystitis Kidney stones Gastroenteritis

Kidney stones Kidney stones cause a sudden onset of severe pain in the lower abdomen. Appendicitis typically starts as a dull, diffuse pain in the periumbilical region. The pain then shifts to severe, sharp, and persistent pain with tenderness that is localized in the right lower quadrant. Cholecystitis is biliary colic, sudden pain in the right upper quadrant that may radiate to the right or left scapula. The patient with gastroenteritis has diffuse and generalized pain accompanied by nausea and diarrhea.

Which organs are located at the right upper quadrant (RUQ) in the abdomen? Liver Cecum Stomach Gallbladder Duodenum

Liver Gallbladder Duodenum

The nurse is assessing the abdomen of a patient with late portal cirrhosis. What is the most probable finding during palpation? Liver is nodular and enlarged Liver is enlarged, smooth, and tender Liver is enlarged, smooth, and nontender Liver is nodular and small, with firm edges

Liver is nodular and enlarged The patient with late portal cirrhosis is likely to have an enlarged, nodular liver same with metastatic cancer or tertiary syphilis.The liver feels enlarged, smooth, and tender to palpation with early heart failure, acute hepatitis, or hepatic abscess. Fatty infiltration and lymphocytic leukemia are some of the conditions in which an enlarged, smooth, nontender liver may be palpated.

The nurse teaches a patient who is prescribed iron supplements about the change in the color of stool. What color should the patient expect? Gray stool Tarry, black stool Red blood in stool Nontarry, black stool

Nontarry, black stool The color and consistency of the stool changes with intake of iron supplements, and the nurse should teach the patient to expect nontarry, black stool when taking this medication. Gray stools occur with hepatitis. The patient may experience tarry, black stools in the presence of occult blood or melena from gastrointestinal bleeding. Red blood may be found in the stools in the presence of gastrointestinal bleeding or localized bleeding around the anus.

While caring for a patient with a feeding tube, which assessment must the nurse use to confirm the feeding tube's position? Obtain a chest x-ray Auscultate the lungs Auscultate the abdomen Visualize gastric aspirates

Obtain a chest x-ray It is mandatory for the nurse to confirm the position of the feeding tube by obtaining a chest x-ray. The nurse must continuously assess the tube by measuring the external portion of the tube and testing the pH of the gastric aspirates. The nurse must not auscultate the lungs or abdomen to determine the placement of the tube. The auscultation of an air bolus can wrongly suggest that the tube is correctly placed in the stomach. This can lead to serious harm resulting from administration of feeding material into the lung. Visualizing the gastric aspirates will only help to determine if the aspirate is gastric or intestinal in origin.

It is often difficult to distinguish between an enlarged kidney and an enlarged spleen. Which characteristic helps the nurse identify an enlarged kidney? Expansion is upward Percussion is tympanitic Presence of a sharp edge Presence of a palpable notch

Percussion is tympanitic The percussion over an enlarged kidney is tympanitic because of the overriding bowel. An enlarged kidney and an enlarged spleen have a similar shape, and both extend forward and down. The kidney has smooth edges, whereas the spleen may have a sharp edge. The spleen retains the splenic notch, whereas the kidney has no palpable notch.

While assessing bowel sounds in a patient, the nurse observes that the sounds have diminished. What disease can the nurse anticipate from the findings? Peritonitis Gastroenteritis Brisk diarrhea Subsiding paralytic ileus

Peritonitis Diminished or absent bowel sound is an abnormal finding caused by disorders in the abdomen. This condition is also called hypoactive bowel sound. Bowel motility may decrease because of an infection caused by peritonitis. Gastroenteritis, subsiding paralytic ileus, and diarrhea are conditions that increase bowel motility. Increased bowel motility results in hyperactive bowel sounds, rather than hypoactive bowel sounds.

The nurse is preparing to assess the abdomen of a patient. What measures must the nurse take while examining the abdominal muscles? Position the patient's arms above the head. Examine painful areas on the abdomen first. Place a pillow under the head and the knees. Ask the patient to maintain a supine position. Obtain the abdominal history during palpation.

Place a pillow under the head and the knees. Ask the patient to maintain a supine position. Obtain the abdominal history during palpation.

The nurse notes frictional rub while auscultating over the lower right rib cage. What does the nurse infer from this finding? Presence of an aortic aneurysm Presence of portal hypertension Presence of renal artery stenosis Presence of an abscess in the liver

Presence of an abscess in the liver

What assessment finding will the nurse document in a patient with an aortic aneurysm? Presence of bruit on auscultation Presence of normal femoral pulses Presence of a smooth, sausage-like mass Presence of a small liver with firm edges

Presence of bruit on auscultation The nurse notes bruits over the aorta on auscultation with firmer pressure in a patient with an aortic aneurysm. The nurse will feel the presence of decreased femoral pulses over the femoral arteries. Most aortic aneurysms are located below the renal arteries and extend to the umbilicus. Focal bulging may be palpable and feel like a pulsating mass in the upper abdomen just to the left of midline. An enlarged, nontender gallbladder feels like a smooth, sausage-like mass. The nurse may feel the presence of a small liver with firm edges in a patient with cirrhosis, not in a patient with an aortic aneurysm.

While assessing a patient's bowel habits, the nurse learns that the patient had passed gray stools. What is the most probable cause of this finding? Use of iron medication Presence of jaundice or hepatitis Localized bleeding around the anus Presence of gastrointestinal bleeding

Presence of jaundice or hepatitis A patient with jaundice or hepatitis is likely to pass gray stools following inflammation of the liver. Using iron medications usually causes black, nontarry stools. The presence of red blood in stools indicates localized bleeding. Gastrointestinal bleeding results in tarry, black stools due to the presence of occult blood or melena.

Which finding should the nurse relate to Cushing syndrome during an assessment? Presence of purple-blue striae Presence of silvery white striae Presence of cutaneous angiomas Presence of brown macular areas

Presence of purple-blue striae A patient with Cushing syndrome is likely to have purple-blue striae on the skin. The skin is fragile and easily broken from normal stretching due to the presence of excess adrenocortical hormone. Striae occur when elastic fibers in the reticular layer of the skin are broken due to rapid or prolonged stretching. Pregnancy or excessive weight gain can also cause striae. They are pink or blue initially and then they turn silvery white. Cutaneous angiomas, or spider nevi, occur with portal hypertension or liver disease. Pigmented nevi or moles are commonly found on the abdomen. They are circumscribed brown macular or papular areas.

The nurse is assessing an infant who is being rocked from side to side. The nurse auscultates a very loud splash in the upper abdomen. What is the most probable cause of this finding? Peritonitis Brisk diarrhea Gastroenteritis Pyloric obstruction

Pyloric obstruction The succussion splash is a very loud splash auscultated over the upper abdomen when the infant is rocked from side to side. It indicates the presence of increased air and fluid in the stomach, which is often seen with pyloric obstruction. Peritonitis causes diminished or absent bowel sounds, indicating decreased motility as a result of inflammation. Borborygmi are loud, gurgling sounds that indicate increased motility and occur with brisk diarrhea and gastroenteritis.

Which quadrant should the nurse assess in a pregnant patient for pain related to appendicitis? Right Upper Quadrant (RUQ) Right Lower Quadrant (RLQ) Left Upper Quadrant (LUQ) Left Lower Quadrant (LLQ)

Right Lower Quadrant (RLQ) "The pregnant patient will feel appendicitis pain in the right lower quadrant (RLQ), because that is where the appendix is located. During pregnancy, the enlarging uterus may displace the appendix upward and to the right. However, the patient will still feel any appendicitis-related pain in the RLQ, not the right upper quadrant (RUQ). The patient does not experience any referred pain; therefore, the pain is not felt in the left upper quadrant (LUQ) or the left lower quadrant (LLQ). "

What should the nurse do to assess the symmetry of the patient's abdomen? Shine a light lengthwise across the patient Ask the patient to exhale and hold the breath Shine a light away from self across the abdomen Ask the patient to perform a sit-up with both hands

Shine a light lengthwise across the patient The nurse should shine a light lengthwise across the patient. This enables the bulges to be highlighted by their shadows. The patient should not exhale and hold the breath, but take a deep breath so that the nurse can identify localized bulging. If the nurse shines the light across the abdomen away from self, the nurse will not be able to see the shadows of the bulges. Therefore, the nurse shines the light across the abdomen toward self. The nurse may ask the patient to perform a sit-up without pushing up with the hands to identify changes in the contour of the abdomen. The deep breath and sit-ups enable the nurse to identify the presence of hernia, enlarged liver, or spleen.

What should the nurse expect to find while assessing the abdomen of a patient with chronic emphysema? The liver span is larger than normal. The liver appears to be displaced downward. The nurse hears a hyper-resonance on percussion. There is dullness on percussion on the upper abdomen.

The liver appears to be displaced downward. The patient with chronic emphysema has hyperinflated lungs, which displace the liver downward. The normal liver span in an adult may vary between 6 cm and 12 cm. A liver span larger than normal indicates hepatomegaly or liver enlargement. Abdominal distention due to gas can cause hyper-resonance on percussion. Ascites, pregnancy, or gas distention in the colon can cause the dullness on percussion to be pushed upward, thus obscuring the lower border of the liver.

Which characteristic helps the nurse to distinguish involuntary rigidity? The muscle area is not painful. The muscle rigidity is bilateral. The muscles constantly feel hard. The muscles relax during exhalation.

The muscles constantly feel hard. Involuntary rigidity is a protective mechanism accompanying acute inflammation of the peritoneum. The nurse feels constant, boardlike hardness on palpation of the muscles. If the area is not painful, the patient is experiencing voluntary guarding. The muscle area becomes painful when the patient increases intra-abdominal pressure by attempting a sit-up. Involuntary rigidity is usually unilateral, whereas voluntary guarding is bilateral. The muscles tend to relax during exhalation if the patient is experiencing voluntary guarding. The muscles with involuntary rigidity do not relax during exhalation.

Which finding during an abdominal assessment does the nurse associate with mononucleosis? The gallbladder feels like a sausage. The spleen feels firm with sharp edges. The spleen feels soft with rounded edges. The gallbladder is enlarged and nontender.

The spleen feels soft with rounded edges. "Splenomegaly occurs with acute infections such as mononucleosis. The spleen enlarges down and to the midline while retaining the splenic notch on the medial edge. The spleen is moderately enlarged and soft, with rounded edges. An enlarged gallbladder feels like a sausage and occurs with acute cholecystitis. A chronic infection can cause the spleen to feel firm, with sharp edges. An enlarged, nontender gallbladder feels like a sausage and occurs when the gallbladder is filled with stones."

During the assessment of a teenager, what findings does the nurse relate to anorexia nervosa? The teenager is eager to lose weight. The teenager tries to induce vomiting. The teenager describes feeling very tired. The teenager has reduced physical activity. The teenager appears to be extremely thin.

The teenager is eager to lose weight. The teenager tries to induce vomiting. The teenager appears to be extremely thin.

Which finding of an umbilical cord during a newborn's assessment is cause for concern? The umbilical cord is white at birth. The umbilical cord has an artery and a vein. The umbilical cord contains Wharton's jelly. The umbilical stump dries within one week.

The umbilical cord has an artery and a vein. The umbilical cord contains two arteries and one vein at birth. The presence of a single artery indicates the risk for congenital defects. The cord is usually white at birth. Normally, the arteries and the vein are surrounded by a mucoid connective tissue called Wharton's jelly. The umbilical stump usually dries up within one week, hardens, and falls off by 10 to 14 days. The area is covered by skin in 3 to 4 weeks.

Which finding during the abdominal assessment of a newborn needs further investigation? Venous hum Diastasis recti Umbilical hernia Occasional peristalsis

Venous hum A venous hum is a rare occurrence which may be heard in the periumbilical region. It originates from the inferior vena cava and may occur with portal hypertension and cirrhotic liver. Diastasis recti is a separation of the rectus muscles with a visible bulge along the midline. It is a normal variation that resolves by early childhood. An umbilical hernia usually appears at 2 to 3 weeks and is especially prominent when the infant cries. The hernia reaches its maximum size at 1 month and usually disappears by 1 year. A newborn's abdominal musculature is thin; therefore, occasionally peristalsis may be visible.