HA T2- Chapter 23

The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment? A. Ask the client to breathe slowly and deeply. B. Perform auscultation prior to palpation. C. Explain the procedure to the client before palpating. D. Position the client sitting upright.

A. Ask the client to breathe slowly and deeply.

The nurse is preparing a client for an abdominal assessment. What should the nurse do prior to the exam? Select all that apply. A. Ask the client to empty the bladder. B. Instruct the client to remove clothing and put on a gown. C. Place the client in the left side lying position. D. Have the client place the arms behind the head. E. Place a pillow or rolled blanket under the client's knees.

A. Ask the client to empty the bladder. B. Instruct the client to remove clothing and put on a gown. E. Place a pillow or rolled blanket under the client's knees.

An instructor is explaining the various causes associated with abdominal distention. Which of the following would the instructor include? Select all that apply. A. Fat B. Stool C. Gas D. Hernia E. Fibroid tumors

A. Fat B. Stool C. Gas E. Fibroid tumors

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved? A. Gallbladder B. Kidneys C. Stomach D. Pancreas

A. Gallbladder

Which strategy by the nurse would best facilitate palpation of a ticklish client's abdomen? A. Have client place hand on the abdomen with the nurse's hand on top. B. Press very firmly on the abdomen so the tickle sensation is absent. C. Distract the client with conversation about family while palpating the abdomen. D. Place a small amount of lubricant on the skin so the nurse's fingers will slide more easily.

A. Have client place hand on the abdomen with the nurse's hand on top.

The nurse is performing a fluid wave test on a client with suspected ascites. How should the nurse perform this test? Place the following steps into the correct order. A. Have the client remain supine. B. Ask the client to place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen. C. Firmly place the palmar surface of the nurse's fingers and hand against one side of the client's abdomen. D. Tap the opposite side of the client's abdominal wall with the other hand.

A. Have the client remain supine. B. Ask the client to place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen. C. Firmly place the palmar surface of the nurse's fingers and hand against one side of the client's abdomen. D. Tap the opposite side of the client's abdominal wall with the other hand.

While performing an abdominal assessment, the nurse auscultates a friction rub over the lower right costal area. The nurse should assess for other findings associated with which condition? A. Hepatic abscess B. Splenic infarction C. The presence of pleural fluid D. Paralyzed diaphragm

A. Hepatic abscess

A nurse determines that the liver span of an older adult male client measures 6 cm at the MCL. How would the nurse would interpret this finding? A. It is a normal-sized liver. B. The liver is larger than normal. C. The liver is smaller than normal. D. The liver has atrophied.

A. It is a normal-sized liver.

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. How would the nurse document this finding? A. Positive Rovsing sign B. Psoas sign present C. Obturator sign positive D. Positive skin hypersensitivity test

A. Positive Rovsing sign

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? A. Quit smoking as soon as possible. B. Exercise for at least 30 minutes, three times per week. C. Eat several small meals a day rather than three larger meals. D. Attend screening clinics at least twice per year.

A. Quit smoking as soon as possible.

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? A. The client is more vulnerable to impaired nutrition due to decreased appetite. B. The client derives less nutritional value from food because of decreased enzyme production. C. The client's liver will be significantly larger than that of a younger client. D. The client will have greater bowel motility than a younger adult.

A. The client is more vulnerable to impaired nutrition due to decreased appetite.

When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication? A. Vitamin supplement with iron B. Nonsteroidal anti-inflammatory drug C. Antidepressant D. Hormone replacement

A. Vitamin supplement with iron

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate? A. "I'm going to examine the area where you're having pain first to get a better picture of what's going on." B. "Before I get ready to examine the painful area, I will let you know in plenty of time." C. "You don't need to worry about anything. I will make sure to be very gentle during the exam." D. "Since you're having pain in a certain area, I won't have to do a very thoroughexam there."

B. "Before I get ready to examine the painful area, I will let you know in plenty of time."

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? A. "Do you feel like you're able to adequately address the stress in your life?" B. "Do you take painkillers like aspirin on a regular basis?" C. "Do you tend to eat foods that are quite high in fat?" D. "Are you currently taking vitamin supplements?"

B. "Do you take painkillers like aspirin on a regular basis?"

A client's bladder is found to be distended. At which location would thenurse begin palpating? A. At the umbilicus B. At the symphysis pubis C. In the right lower quadrant D. In the left lower quadrant

B. At the symphysis pubis

The nurse is percussing a client's liver and is assessing liver descent. What would the nurse have the client do next? A. Cough forcefully B. Hold the breath C. Breathe in and out deeply D. Perform the Valsalva maneuver

B. Hold the breath

A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor? A. Excessive fat and sugar intake B. Overuse of laxatives C. Obesity D. Inadequate abdominal muscle tone

B. Overuse of laxatives

What would a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration? A. Hepatomegaly B. Splenomegaly C. Abdominal mass D. Intestinal air

B. Splenomegaly

11. When measuring abdominal girth in a client with ascites, the nurse would place the client in which position? A. Sitting B. Standing C. Supine D. Prone

B. Standing

A client is experiencing parietal abdominal pain. The nurse would expect the client to describe the pain as which type of sensation? A. Dull B. Steady C. Cramping D. Burning

B. Steady

A nurse is describing viscera to a group of nursing students in the clinical area, differentiating solid viscera from hollow viscera. Which of the following would the nurse describe as hollow viscera? Select all that apply. A. Liver B. Stomach C. Pancreas D. Gallbladder E. Small intestine F. Urinary bladder

B. Stomach D. Gallbladder E. Small intestine F. Urinary bladder

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem? A. Abdominal respiratory movements B. Visible peristaltic waves C. Symmetric appearance D. No bulging with head raising

B. Visible peristaltic waves

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? A. Absorbing electrolytes B. Secreting digestive enzymes C. Absorbing large amounts of water D. Secreting bile

C. Absorbing large amounts of water

Assessment of a client's abdomen reveals a positive Murphy sign. Which of the following would the nurse suspect? A. Ascites B. Appendicitis C. Cholecystitis D. Splenomegaly

C. Cholecystitis

A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? A. Tenderness on palpation B. Diastasis recti C. Cullen sign D. Tympany on percussion

C. Cullen sign

While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating what complication? A. Hernia B. Malignancy C. Infection D. Aneurysm

C. Infection

A group of students is preparing for their clinical experience, in which they are required to demonstrate the techniques for examining the abdomen. The students show understanding of the proper sequence when they demonstrate the techniques in which order? A. Palpate, percuss, inspect, auscultate B. Auscultate, inspect, palpate, percuss C. Inspect, auscultate, percuss, palpate D. Percuss, inspect, auscultate, palpate

C. Inspect, auscultate, percuss, palpate

The nurse is preparing to perform an abdominal assessment for a client. What would be most appropriate for the nurse to do to promote relaxation of the client's abdominal muscles? A. Encourage the client to hold their breath. B. Cover the client in a warm blanket. C. Place a pillow under both of the client's knees. D. Assure the client that painful areas will not be examined.

C. Place a pillow under both of the client's knees.

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? A. Right upper quadrant B. Left upper quadrant C. Right lower quadrant D. Left lower quadrant

C. Right lower quadrant

When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following? A. Flat B. Rounded C. Scaphoid D. Protuberant

C. Scaphoid

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant? A. Gallbladder B. Liver C. Spleen D. Head of pancreas

C. Spleen

The nurse is performing blunt percussion of a client's kidneys. For what abnormal finding is the nurse primarily assessing? A. Dullness B. Tympany C. Tenderness D. Hyperresonance

C. Tenderness

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen? A. Accentuated tympany B. Hyperresonance C. Tympany D. Dullness

C. Tympany

A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. What bowel sound would the nurse expect to assess in this client? A. Normoactive B. Hyperactive C. Hypoactive D. Absent

D. Absent

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next? A. Review the client's blood work for low platelets and hemoglobin. B. Assess the client for signs and symptoms of fluid volume overload. C. Assess the client's nutritional status. D. Assess the client for other signs and symptoms of liver disease.

D. Assess the client for other signs and symptoms of liver disease.

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? A. Refer the client for medical follow-up. B. Evaluate further for a problem with the spleen. C. Assess urinary output. D. Document the position of the liver.

D. Document the position of the liver.

The nurse is performing an abdominal assessment on a client with suspected appendicitis. How should the nurse assess for psoas sign in the client? A. Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing B. Tapping finger pads over the client's abdominal wall, feeling for a floating mass C. Flexing the client's right hip and knee, rotating the hip internally and externally D. Flexing the client's right hip, applying downward pressure on the right thigh

D. Flexing the client's right hip, applying downward pressure on the right thigh

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment? A. Repeat auscultation in four to six hours. B. Palpate the client's abdomen to stimulate bowel motility. C. Perform abdominal percussion, and then repeat auscultation. D. Listen for five minutes before documenting an absence of bowel sounds.

D. Listen for five minutes before documenting an absence of bowel sounds.

A nurse is preparing to palpate a client's spleen. Which position would the nurse use to facilitate palpation? A. Sitting B. Lying prone C. Left side-lying D. Right side-lying

D. Right side-lying

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus? A. Refer the client to an oncologist. B. Provide a dietician consult for the client. C. Counsel the client regarding hernia repair. D. Stop palpating and get medical assistance.

D. Stop palpating and get medical assistance.

Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions? A. Shifting dullness B. Fluid wave C. Abdominal x-ray D. Ultrasound

D. Ultrasound