HA- GI PrepU
A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem?
"Do you take painkillers like aspirin on a regular basis?" Explanation: Regular use of nonsteroidal anti-inflammatory medications (NSAIDs) is implicated in the incidence of PUD. Stress is a contributing, but not causative, factor. Vitamin supplements and a high-fat diet are not considered to be causative factors.
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?" Explanation: Striae are silvery white marks that are common on the abdomen from stretching of the skin during pregnancy or weight gain. They do not cause pain or any other color changes to the skin. High blood pressure may cause the dilation of the superficial arterioles or capillaries with a central star pattern (spider angioma) but would not result in striae.
Which of the following acute abdominal symptoms could be life threatening?
Abdominal pain Explanation: Severe dehydration from nausea and vomiting, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Striae, or stretch marks, usually accompany pregnancy or changes in weight and are not of themselves life threatening. Kidney stones are a disorder, not a symptom. Acute indigestion is usually not life threatening.
The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?
Absorbing large amounts of water Explanation: The colon functions primarily to secrete large amounts of alkaline mucus to lubricate the intestine and neutralize acids formed by the intestinal bacteria. Water is also absorbed through the large intestine, leaving waste products to be eliminated in stool. The colon does not secrete enzymes or bile, and it does not absorb significant quantities of electrolytes.
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?
Acute pancreatitis Explanation: 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 management, and bowel rest.
A client presents at the clinic with a chief complaint of "indigestion." The patient tells the nurse, "It usually happens after I do things like mowing the lawn or doing other yard work." What should the nurse suspect?
Angina Explanation: Note that angina from inferior wall coronary artery disease may present as "indigestion," but is precipitated by exertion and relieved by rest.
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's bladder is found to be distended. At which location should the nurse begin palpating?
At the symphysis pubis Explanation: 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.
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 Explanation: When blood is exposed to the environment of the stomach, it often resembles "coffee grounds." This is not always recognized by clients as blood, so it is important to inquire about this. This symptom is not common in cholecystitis, and the other possibilities are lower in the intestine. It should be noted that conversely, a rapid bleed from the stomach or other upper gastrointestinal source can produce bright red blood in the stool. Do not rule out a proximal bleed based on the absence of "coffee grounds." Likewise, bright red blood in the emesis may originate from the stomach. Black, sticky stools also can accompany upper GI bleeds.
Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect?
Cholecystitis Explanation: 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.
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 Explanation: Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.
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 Explanation: Older adult clients are prone to urinary tract infections because the activity of protective bacteria in the urinary tract declines with age. It is not established that older adults have poorer hydration or nutrition than younger adults. A higher fat-to-lean muscle ratio would not affect risk for urinary tract infections.
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 Explanation: 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.
An instructor is explaining the various causes associated with abdominal distention. Which of the following would the instructor include? Select all that apply.
Fibroid tumors, Fat, Stool and Gas Explanation: The major causes of abdominal distention are sometimes referred to as the "6 F's" and include fat, feces, fetus, fibroids, flatulence, and fluid.
The nurse notes that a client's abdominal skin is pale and taut. What should the nurse suspect is causing this finding?
Fluid accumulating in the abdominal cavity Explanation: Pale taut skin may be seen with ascites which is significant abdominal swelling that indicates fluid accumulation in the abdominal cavity. Jaundice would be present if the liver is inflamed. Purple discoloration at the flank areas indicates bleeding within the abdominal wall. Dilated veins may be seen with obstruction of the inferior vena cava.
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 Explanation: Pale and taut skin indicates significant abdominal swelling caused by accumulation of fluid in the abdominal cavity, or ascites. Bleeding within the abdominal wall would manifest as purple discoloration at the flanks. Inflammation of the peritoneum and obstruction of the intestine does not contribute to pale and taut abdominal skin.
Which of the following people need to be vaccinated for hepatitis A and B?
Food-service workers
A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?
Gastric ulcer Explanation: 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. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine.
The nurse is percussing a client's liver and is assessing liver descent. What would the nurse have the client do next?
Hold the breath Explanation: 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.
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 Explanation: 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.
The nurse understands that the liver does what?
Produces clotting factors Explanation: The liver produces clotting factors. The pancreas secretes insulin, amylase and lipase.
An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide?
Quit smoking as soon as possible.
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 Explanation: 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.
Rovsing's sign is a test of referred rebound tenderness in appendicitis.
True Explanation: Pain in the RLQ during pressure in the LLQ is a positive Rovsing's sign. It suggests acute appendicitis.
The pancreas of an adult client is located
deep in the upper abdomen and is not normally palpable. Explanation: The pancreas, located mostly behind the stomach deep in the upper abdomen, is normally not palpable. It is a long gland extending across the abdomen from the RUQ to the LUQ.
The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation?
identify abdominal organs Explanation: Deep palpation is performed to identify abdominal organs. Light palpation is completed to discern muscular resistance, detect abdominal tenderness, and complete a surface evaluation.
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 Explanation: 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 colon originates in this abdominal area:
right lower quadrant. Explanation: 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.
Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is
usually difficult to localize
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit Explanation: Auscultation of the abdomen would reveal a bruit. The client may exhibit decreased femoral pulses, hypotension and cool extremities.
The nurse is assessing the abdomen of a client. While percussing the abdomen, what normal sound does the nurse expect to hear?
Tympany Explanation: Generalized tympany predominates over the abdomen because of air in the stomach and intestines. An enlarged area of dullness would be heard over an enlarged liver or spleen. A friction rub heard over the lower right costal area is associated with hepatic abscess or metastases. A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction, abscess, infection, or tumor. A hollow sound would not be expected at the normal spleen.
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) Explanation: 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.
During an assessment, the patient describes vomiting moderate amounts that "smell like poop." The nurse might suspect
small bowel obstruction Explanation: Vomiting and pain indicate small bowel obstruction. Fecal odor occurs with small bowel obstruction and gastrocolic fistula.
Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?
Appendicitis Explanation: This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.
The nurse would assess for positive Blumberg sign how?
Applying and releasing pressure to the abdomen Explanation: Pain that occurs after applying and releasing pressure to the abdomen would be a positive Blumberg sign. Murphy sign occurs when the client holds his breath and there is pain. Blunt pressure at the CVA assesses for kidney pain. Liver span test occurs at the MCL.
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 Explanation: 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.
The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by
Cirrhosis and nephrosis Explanation: Ascites is the accumulation of fluid in the abdomen. The fluid descends with gravity, resulting in dullness to percussion in the lowest point of the abdomen based on client position. Changing the client's position should move the fluid shift to the most dependent point. Ascites occurs in cirrhosis of the liver, congestive heart failure, nephrosis, peritonitis, and metastatic neoplasms. The other options are distracters to the question.
What causes the characteristic features of coffee-ground emesis?
Digested blood Explanation: Coffee-ground emesis is digested blood; bloody emesis is an active bleed with undigested blood. Green emesis usually results from reduced peristalsis with irritation.
During deep palpation of the client's abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which nursing action would be most appropriate?
Document the position of the liver. Explanation: 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.
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 Explanation: For more chronic symptoms, dyspepsia is defined as chronic or recurrent discomfort or pain centered in the upper abdomen.
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 Explanation: 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.
A 46-year-old former salesman presents to the ER complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. Examination shows a man appearing older than his stated age. His skin has a yellowish tint and he is thin with a prominent abdomen. Multiple "spider angiomas" are at the base of his neck. Otherwise his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs?
Esophageal varices Explanation: Varices are often found in clients with alcoholism, but only when they have a diagnosis of significant cirrhosis. This client has symptoms of cirrhosis including jaundice, ascites, spider hemangiomas, and dilated veins noted on his abdomen (caput medusa).
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 other bacteria listed are not associated with peptic ulcer disease.
A daycare worker presents to the office with jaundice. She denies IV drug use, blood transfusion, and travel, and has not been sexually active for the past 10 months. Which type of hepatitis is most likely?
Hepatitis A Explanation: The lack of blood and body fluid contact makes hepatitis B, C, and D unlikely. If she regularly changes the diapers of the children in her care she is at risk for hepatitis A. Vaccine against hepatitis A is recommended for daycare workers.
A 42-year-old florist comes to the office complaining of chronic constipation for the last 6 months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies any recent illnesses or injuries. She denies any changes to her diet or exercise program. She is on no new medications. During review of systems the client says that she has felt fatigued, had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one vaginal delivery and two c-sections. She is married with three children and she owns her own flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has coronary artery disease. There is no family history of cancers. On examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the Achilles tendons. What is the best choice for the cause of her constipation?
Hypothyroidism Explanation: Many metabolic conditions can interfere with bowel motility. In this case the client has many symptoms of hypothyroidism including cold intolerance, weight gain, fatigue, constipation, and irregular menstrual cycles. On examination, thyromegaly and delayed reflexes can help to make the diagnosis. Medication will usually correct these symptoms.
The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates?
Inflammation of the gallbladder Explanation: Pain with breathing while assessing Murphy sign is an indication of inflammation of the gallbladder. Peritonitis is assessed for rebound tenderness, indicated by Blumberg sign (a sharp, stabbing pain as the examiner releases pressure from the abdomen). Kidney pain is assessed by performing blunt percussion at the costovertebral angles (CVA). Appendicitis is assessed with the iliopsoas muscle test.
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 Explanation: The key to this question is the presence of the scar. The scar in the right lower quadrant should alert the nurse to the possibility of internal adhesions which account for the pulling feeling the client reports. An intestinal obstruction would not produce a pulling feeling but the client most likely would report nausea and vomiting. With a right lower quadrant scar, the appendix may already be removed. Acute appendicitis would also present with fever, nausea and vomiting. Peritonitis would cause a rigid abdomen with generalized severe abdominal pain, and fever.
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 Explanation: 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 Explanation: 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 determines that the liver span of an older adult male client measures 6 cm. How would the nurse would interpret this finding?
It is a normal-sized liver. Explanation: The normal liver span is 6 to 12 cm, so this is a normal finding. Liver size begins to decrease after age 50. If the measurement was greater than 12 cm, the client's liver would be enlarged. A decreased span suggests liver atrophy.
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?
It is a splenic rub. Explanation: A rough, grating noise over this area represents a splenic rub, which can accompany splenic infarction. Rubs also occur over the liver and pleura and pericardium.
A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10-year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time?
Listen with the bell of the stethoscope for vascular sounds Explanation: A client with a history of hypertension is at risk for bruits over any of the vascular areas on the abdomen such as renal artery, iliac artery, or femoral artery. The bell of the stethoscope is used for this assessment because bruits are low-pitched, murmur-like sounds. Inspection of the abdomen should be performed before auscultation. Vital signs are part of the general survey and are usually the first hands-on assessment of a client. Measuring abdominal girth is done if the nurse observes a distended abdomen or there are other signs of fluid retention within the abdomen.
A nurse cares for a client with a duodenal ulcer. The nurse knows that which characteristic of pain is generally associated with the client's condition?
May awaken the client at night Explanation: A client with duodenal ulcers would have severe pain that awakens him at night. The pain may not increase by the intake of food but may be relieved by it. The pain is unrelated to drinking water. The nature of the pain may vary and may not necessarily be throbbing.
You are assessing a patient for acute cholecystitis. What sign would you assess for?
Murphy sign Explanation: 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.
During the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign?
Murphy's Explanation: 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. The obturator sign involves pain in the right lower quadrant as a result of the nurse flexing the client's hip and rotating the leg externally and internally while supporting the client's right knee and ankle. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.
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?
Murphys Explanation: 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.
To promote relaxation of the 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. Explanation: 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.
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 Explanation: Findings indicating referred rebound tenderness is a positive Rovsing's sign. Psoas sign occurs when pain in the right lower quadrant occurs with raising of the client's right leg from the hip and pressure applied downward against the lower thigh. The obturator sign occurs when pain in the right lower quadrant results when the client's right knee and ankle are supported and the leg is rotated internally and externally. A positive hypersensitivity test occurs when the client experiences pain or exaggerated sensation when the abdomen is stroked with a sharp object.
The client with a acute appendicitis has been ordered a barium enema. What should the nurse do first?
Question the order as a barium enema is contraindicated in acute appendicitis Explanation: A barium enema should not be performed on a client suspected of having an acute inflammatory condition, such as appendicitis, diverticulitis, or ulcerative colitis, or who has a perforated hollow organ. The barium enema can cause an inflamed area of the bowel to rupture and death may result.
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 Explanation: Pancreatic inflammation, or pancreatitis, may be felt in the back. This is called "referred" pain because the pain is not felt at its source. This is not radiated pain, which extends continuously to the tissues surrounding the source, nor is it localized pain, which remains only in one small area. It is not chronic pain, as it results from acute pancreatitis.
A client expresses pain when the left costovertebral angle is palpated. What should the nurse suspect is occurring with this client? Select all that apply.
Renal calculi, Hydronephrosis and Kidney infection Explanation: Tenderness or sharp pain elicited over the costovertebral angle occurs with renal calculi, hydronephrosis, or a kidney infection. Tenderness over the liver is associated with hepatitis and cholecystitis.
The nurse is evaluating a new graduate's ability to perform a rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?
Right lower quadrant Explanation: 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 would the nurse use to facilitate palpation?
Right side-lying Explanation: Having the client lie on his or her right side may facilitate splenic palpation by moving the spleen downward and forward. Alternatively, the client may be positioned supine.
The nurse is caring for a client being treated for a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part?
Small intestine Explanation: Absorption of nutrients takes place almost exclusively in the small intestine. The esophagus propels the food bolus by means of slow peristaltic movements into the stomach. The descending colon is part of the large intestine. Mastication occurs in the mouth, then food moves into the oropharynx and esophagus for food propulsion through the digestive tract.
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 Explanation: 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 biochemical used in the digestion process.
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 Explanation: 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 diaphragmatic displacement.
What would a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?
Splenomegaly Explanation: Normally, tympany or resonance is heard at the last left interspace. Dullness suggests splenomegaly. The liver would be percussed anteriorly. An increased liver span would suggest hepatomegaly. Percussion and palpation in any area of the abdomen might reveal an abdominal mass. Intestinal air would be noted by tympany.
During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take?
Stop palpating and get medical assistance. Explanation: If the nurse palpates a prominent pulsating mass, the suspicion is high for an abdominal aortic aneurysm. The nurse should stop palpating immediately and seek medical assistance because the risk of rupture is great. The mass does not suggest a malignancy or hernia, nor does it indicate a need for a dietary consult.
A 52-year-old secretary comes to the office complaining about accidentally leaking urine when she coughs or sneezes. She says this has been going on for about 1 year. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is significant for four spontaneous vaginal deliveries. She is married with four children. She denies alcohol, tobacco, or drug use. Pelvic examination reveals some atrophic vaginal tissue but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable. Which type of urinary incontinence does she have?
Stress incon. Explanation: Stress incontinence usually occurs when the intra-abdominal pressure goes up during coughing, sneezing, or laughing. This is usually from a weakness of the pelvic floor with inadequate muscle support of the bladder. Vaginal deliveries and pelvic surgery are often associated with these symptoms. Usually female clients are postmenopausal when stress incontinence begins. Kegel exercises are usually recommended to strengthen the pelvic floor muscles
The nurse is performing blunt percussion of a client's kidneys. For what abnormal finding is the nurse primarily assessing?
Tenderness Explanation: This form of percussion is done not to elicit sound but rather to determine the presence of tenderness that may indicate inflammation or infection.
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. Explanation: Older adults experience a decline in appetite, although enzyme production does not significantly decrease. The liver decreases in size with age. Bowel motility declines as well, making the older adult vulnerable to constipation.
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 Explanation: The nurse should avoid touching tender or painful areas until last and reassure the client. The area needs to be assessed for the presence of abnormal findings and should not be avoided. Medicating before palpating may obscure the findings. The client may not be able to relax just by the power of suggestion.
A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem?
Visible peristaltic waves Explanation: Visible peristaltic waves typically are not visible except in very thin people. An increase in peristaltic waves with progression in a ripple like fashion suggests intestinal obstruction, necessitating further evaluation. Abdominal respiratory movements are normal findings in a male client. Symmetric appearance and absence of bulging when the client raises his head are also normal findings.
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 Explanation: 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.
The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the
costovertebral angle. Explanation: - Kidney tenderness is best assessed at the costovertebral angle. - 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 for liver tenderness is elicited by placing the left hand flat against the lower rib cage & striking it with the ulnar side of the right fist. Percussion of the spleen begins in the left mid-axillary line & progresses downward until the sound changes from lung resonance to splenic dullness. The gallbladder is not percussed.
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should
palpate deeply while quickly releasing pressure. Explanation: If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen away from the painful or tender area. Then suddenly release pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred.
To palpate the spleen of an adult client, the nurse should
place the right hand below the left costal margin. Explanation: To palpate the spleen stand at the client's right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the client's head. Ask the client to inhale and press inward and upward as you provide support with your other hand.
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. Explanation: Assess for psoas sign by asking the client to lie on the left side. Hyperextend the right leg of the client.
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. Explanation: Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client's abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants.