Health Assessment Abdomen
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? A) Positive Rovsing's sign B) Psoas sign C) Obturator sign D) Positive skin hypersensitivity test
a
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) Gall bladder B) Kidneys C) Stomach D) Pancreas
a
A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following? 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
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
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
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 b c e
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
A client's bladder is found to be distended. At which location would the nurse begin palpating? A) At the umbilicus B) At the symphysis pubis C) In the right lower quadrant D) In the left lower quadrant
b
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
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 thorough exam there."
b
The nurse is preparing to assess the size of the aorta. The nurse would palpate at which location? A) Midline at the umbilicus B) Deep epigastrium to the left of midline C) Slightly above the suprapubic area D) Between the umbilicus and the symphysis pubis
b
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
Which of the following would a nurse suspect if dullness is percussed at the last interspace at the anterior axillary line on deep inspiration? A) Hepatomegaly B) Splenomegaly C) Abdominal mass D) Intestinal air
b
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 d e f
A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate 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
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
A nurse suspects intra-abdominal bleeding in a client who was involved in a motor vehicle accident 3 days ago. Which finding would the nurse most likely have noted? A) Tenderness on palpation B) Diastasis recti C) Cullen's sign D) Tympany on percussion
c
After teaching a group of students about the important organs to be assessed during an abdominal assessment, the instructor determines that the teaching was successful when the students identify which organ as the largest solid organ in the body? A) Pancreas B) Spleen C) Liver D) Kidney
c
Assessment of a client's abdomen reveals a positive Murphy's sign. Which of the following would the nurse suspect? A) Ascites B) Appendicitis C) Cholecystitis D) Splenomegaly
c
The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location? A) Right upper quadrant B) Left upper quadrant C) Right lower quadrant D) Left lower quadrant
c
The nurse is percussing a client's' liver and is assessing liver descent. The nurse would have the client do which of the following? A) Cough forcefully B) Hold his or her breath C) Breathe deeply D) Perform the Valsalva maneuver
c
To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do? A) Encourage the client to hold his or her 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
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
While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following? A) Hernia B) Malignancy C) Infection D) Aneurysm
c
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
A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following? A) Normoactive B) Hyperactive C) Hypoactive D) Absent
d
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
During deep palpation of the abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following 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
The nurse demonstrates the correct technique for assessing the psoas sign by which action? A) Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing B) Tapping fingerpads 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
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
