Health Assessment Ch 20: Abdominal Assessment

33. The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? a. Blacks b. Hispanics c. Whites d. Asians

a. Blacks

1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b. Tympany c. Resonance d. Hyperresonance

a. Dullness The liver is located in the right upper quadrant and would elicit a dull percussion note.

29. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen. b. Flatness in the right upper quadrant. c. Hyperresonance in the left upper quadrant. d. Tympany in the right and left lower quadrants.

a. Dullness across the abdomen. A large amount of ascitic fluid produces a dull sound to percussion.

10. When documenting a finding over the stomach, the nurse most accurately identifies the region as: a. Epigastric b. Hypogastric c. RUQ d. LUQ

a. Epigastric. The epigastric region is located above the umbilicus and straddles the midline between the right and left upper quadrants.

19. A nurse notices that a patient has ascites, which indicates the presence of: a. Fluid. b. Feces. c. Flatus. d. Fibroid tumors.

a. Fluid.

3. When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved? a. Liver b. Spleen c. Sigmoid colon d. Kidney

a. Liver

The nurse is palpating in the right upper abdominal quadrant and feels an enlarged area. The nurse recognizes that she is most likely feeling what organ? a. Liver b. Pancreas c. Kidneys d. Gallbladder

a. Liver The liver is located in the RUQ. The gallbladder and kidney are not palpable. The pancreas is located in the LUQ.

8. A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? a. Murphy sign b. Psoas sign c. Rovsing sign d. Obturator sign

a. Murphy sign. The murphy sign tests for gallbladder pain. The other signs test for peritoneal irritation in the lower quadrants.

The client with a acute appendicitis has been ordered a barium enema. What should the nurse do first? a. Question the order as a barium enema is contraindicated in acute appendicitis. b. Obtain a signed consent from the client. c. Make sure the client understands why the barium enema has been ordered. d. Notify radiology of the order.

a. Question the order as a barium enema is contraindicated in acute appendicitis.

32. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Sigmoid colon c. Appendix d. Gallbladder

a. Spleen The spleen is located in the LUQ of the abdomen.

26. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patients abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least: a. 1 minute. b. 5 minutes. c. 10 minutes. d. 2 minutes in each quadrant.

b. 5 minutes.

23. The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? a. Abdominal tone is increased. b. Abdominal musculature is thinner. c. Abdominal rigidity with an acute abdominal condition is more common. d. The older adult with an acute abdominal condition complains more about pain than the younger person.

b. Abdominal musculature is thinner.

Which of the following acute abdominal symptoms could be life threatening? a. Indigestion b. Abdominal pain c. Kidney stones d. Striae

b. Abdominal pain. Severe dehydration from n/v, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Kidney stones are a disorder, not a symptom.

17. An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. Increased gastric acid secretion. b. Decreased gastric acid secretion. c. Delayed gastrointestinal emptying time. d. Increased gastrointestinal emptying time.

b. Decreased gastric acid secretion. Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption).

7. A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg (20 lb) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? a. Listen for a fluid wave. b. Percuss the abdomen for shifting dullness. c. Auscultate for lymph nodes. d. Stroke the abdomen to elicit the abdominal reflex.

b. Percuss the abdomen for shifting dullness. Percussing elicits a change from tympany to dullness when the abdomen is in its most dependent position. Fat remains static.

10. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a. Diarrhea. b. Peritonitis. c. Laxative use. d. Gastroenteritis.

b. Peritonitis. Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.

15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. Diarrhea. b. Pyrosis. c. Dysphagia. d. Constipation.

b. Pyrosis. Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct.

27. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test. b. Test for Murphy sign. c. Assess for rebound tenderness. d. Iliopsoas muscle test.

b. Test for Murphy sign.

1. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. a. Test for the Murphy sign. b. Test for the Blumberg sign. c. Test for shifting dullness. d. Perform the iliopsoas muscle test. e. Test for fluid wave.

b. Test for the Blumberg sign. d. Perform the iliopsoas muscle test. Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites.

14. During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area. b. Tympanic percussion note in the umbilical region. c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line. d. Dull percussion note in the left upper quadrant at the midclavicular line.

b. Tympanic percussion note in the umbilical region. Tympany should predominate in all four quadrants of the abdomen because air in the intestine rises to the surface when the person is supine. Vascular bruits are not normally present. Normally, the spleen is not palpable. Dullness would not be found in the area of lung resonance (LUQ at the MCL).

25. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a. A bruit is absent. b. Femoral pulses are increased. c. A pulsating mass is usually present. d. Most are located below the umbilicus.

c. A pulsating mass is usually present.

22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? a. Spleen b. Sigmoid c. Appendix d. Gallbladder

c. Appendix. The appendix is located in the RLQ. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the RLQ.

Why is the appearance of urine important to evaluate during an abdominal examination? a. Sediment in the urine could indicate malnutrition. b. Cloudy urine rules out UTI. c. Dark urine may be from dehydration. d. Blood could indicate cholecystitis.

c. Dark urine may be from dehydration. Cloudy urine may indicate UTI. Sediment may indicate kidney disease. Blood can be caused from renal injury, renal disease, or trauma to a catheter. Dark urine may be from dehydration.

39. During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!" Based on these symptoms, the nurse suspects that the patient has which condition? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis

c. Duodenal ulcer Pain associated with duodenal ulcers occurs 2-3 hours after a meal; it may be relieved by more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.

5. A patient with a history of kidney stones presents with complaints of pain, hematuria, and n/v. What assessment technique will elicit kidney pain? a. Inspection with indirect lighting. b. Iliopsoas muscle sign. c. Indirect percussion for CVA tenderness. d. Blumberg sign.

c. Indirect percussion for CVA tenderness. Fist percussion over the costovertebral angle (CVA) is the only technique listed that reflects a technique for assessing the kidney.

18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: a. Ovary infection. b. Liver enlargement. c. Kidney inflammation. d. Spleen enlargement.

c. Kidney inflammation. Sharp pain along the costovertebral angles occurs with inflammation of the kidney or perinephric area.

6. When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following? a. Right renal artery b. Right femoral artery c. Right iliac artery d. Abdominal aorta

c. Right iliac artery. The iliac arteries are located to the left and right of the midline of the abdomen, below the umbilicus. The aorta is midline, the renal artery is above the umbilicus, and the femoral artery is located in the groin.

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? a. Liver b. Pancreas c. Spleen d. Gallbladder

c. Spleen.

16. The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. Flatness, resonance, and dullness. b. Resonance, dullness, and tympany. c. Tympany, hyperresonance, and dullness. d. Resonance, hyperresonance, and flatness.

c. Tympany, hyperresonance, and dullness. Tympany, which should predominate because air in the intestines rises to the surface when the person is supine. Hyperresonance, which may be present with gaseous distension. Dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.

6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a. The spleen can be enlarged as a result of trauma. b. The spleen is normally felt on routine palpation. c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine size. d. An enlarged spleen should not be palpated because it can easily rupture.

d. An enlarged spleen should not be palpated because it can easily rupture. If an enlarged spleen is felt, the nurse should refer the person and should not continue to palpate it.

The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sound as what? a. Borborygmi b. Venous hum c. Friction rub d. Bruit

d. Bruit Bruits are swishing sounds that indicate turbulent blood flow. Borborygmi is increased bowel sounds. A venous hum is a soft-pitched humming sound associated with partial obstruction of an artery and reduced blood flow to the organ. Friction rubs are grating sounds with inspiration.

31. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d. Consider this finding as normal, and proceed with the examination.

d. Consider this finding as normal, and proceed with the examination. A liver span of 10.5 cm is the mean for males and 7 cm for females. A liver span of 11 cm is within normal limits for this individual.

The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant? a. Hum b. Hollow tympanic notes c. Rub d. Dullness

d. Dullness Normal percussion findings include dullness over the liver in the RUQ and hollow tympanic notes in the LUQ over the gastric bubble. Hums and rubs are ausculatory sounds.

34. The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem? a. Hypertension. b. Streptococcal infections. c. Recurrent constipation with frequent laxative use. d. Frequent use of nonsteroidal antiinflammatory drugs.

d. Frequent use of nonsteroidal antiinflammatory drugs.

13. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a. Loud continual hum. b. Peritoneal friction rub. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds.

d. Hyperactive bowel sounds. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.

9. Which assessment technique best confirms splenic enlargement? a. Deep palpation under the left costal margin. b. First percussion of the spleen with the patient in a sitting position. c. Deep palpation over the RUQ with the patient lying on the right side. d. Percussion along the left MAL spleen and gentle palpation.

d. Percussion along the left MAL spleen and gentle palpation. Percussion is the best technique to estimate the size of the spleen; gentle palpation is necessary to reduce the risk of splenic rupture.

7. A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: a. Obese. b. Herniated. c. Scaphoid. d. Protuberant.

d. Protuberant. A protuberant abdomen is rounded, bulging, and stretched. A scaphoid abdomen caves inward.

2. Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum c. Gallbladder d. Sigmoid colon

d. Sigmoid colon

4. What percussion sound is heard over most of the abdomen? a. Resonance b. Hyperresonance c. Dullness d. Tympany

d. Tympany. The small intestine and colon, which are hollow organs, are predominant over most of the abdominal cavity. The result is tympany as the percussion sound.

4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a.Percuss and palpate in the lumbar region. b.Inspect and palpate in the epigastric region. c.Auscultate and percuss in the inguinal region. d.Percuss and palpate the midline area above the suprapubic bone.

d.Percuss and palpate the midline area above the suprapubic bone. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.