Health assessment Jarvis Chapter 21: Abdomen w/exp

A nurse notes that a patient has ascites, which indicates that which of the following is present? 1. Fluid 2. Feces 3. Flatus 4. Fibroid tumors

ANS: 1 Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

Just before going home, a new mother asks the nurse about the umbilical cord. The nurse would tell her: 1. it should fall off by 10 to 14 days. 2. at birth the cord is a bluish color. 3. it contains two veins and one artery. 4. skin will cover the area within 1 week.

ANS: 1 At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton's jelly. The umbilical stump dries within a week, hardens, and falls off by 10 to 14 days. Skin will cover the area by 3 to 4 weeks.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: 1. projectile vomiting. 2. hypoactive bowel activity. 3. palpable olive-sized mass in right lower quadrant. 4. pronounced peristaltic waves crossing from right to left.

ANS: 1 Marked peristalsis together with projectile vomiting in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.

Which sound is normal to elicit when percussing in the seventh right intercostal space at the midclavicular line over the liver? 1. Dullness 2. Tympany 3. Resonance 4. Hyperresonance

ANS: 1 The liver is located in the right upper quadrant and would elicit a dull percussion note.

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: 1. One minute. 2. Five minutes. 3. Ten minutes. 4. Two minutes in each quadrant.

ANS: 2 Absent bowel sounds are rare. The nurse must listen for 5 minutes by the watch before deciding bowel sounds are completely absent.

The nurse is listening to bowel sounds. Which of the following is true of bowel sounds? 1. They are usually loud, high-pitched, rushing, tinkling sounds. 2. They are usually high-pitched, gurgling, irregular sounds. 3. They sound like "two pieces of leather being rubbed together." 4. They originate from the movement of air and fluid through the large intestine.

ANS: 2 Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: 1. diarrhea. 2. peritonitis. 3. laxative use. 4. gastroenteritis.

ANS: 2 Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.

A patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: 1. increased gastric acid secretion. 2. decreased gastric acid secretion. 3. delayed gastrointestinal emptying time. 4. increased gastrointestinal emptying time.

ANS: 2 Gastric acid secretion decreases with aging, and this may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium.

Which of the following statements regarding the aging adult and abdominal assessment is true? 1. The abdominal tone is increased. 2. The abdominal musculature is thinner. 3. The abdominal rigidity with acute abdominal conditions is more common. 4. The aging person complains of more pain with an acute abdomen than a younger person would.

ANS: 2 In the aging person, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with acute abdominal conditions is less common in aging. The aging person often complains less of pain than a younger person would with an acute abdomen.

28. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse will conduct which of the following to assess for this condition? 1. Obturator test 2. Murphy's sign 3. Assess for rebound tenderness 4. Iliopsoas muscle test

ANS: 2 Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration. The person feels sharp pain and abruptly stops inspiration midway.

The nurse is assessing the abdomen of a pregnant woman, who is complaining of having a "stomach ache" all the time. The nurse knows that esophageal reflux during pregnancy can cause: 1. diarrhea. 2. pyrosis. 3. dysphagia. 4. constipation.

ANS: 2 Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy.

The main reason auscultation precedes percussion and palpation of the abdomen is to: 1. determine areas of tenderness before using percussion and palpation. 2. prevent distortion of bowel sounds that might occur after percussion and palpation. 3. allow the patient more time to relax and therefore be more comfortable with the physical examination. 4. prevent distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation.

ANS: 2 This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

Which of the following is a normal finding in the abdominal assessment? 1. The presence of a bruit in the femoral area 2. A tympanic percussion note in the umbilical region 3. A palpable spleen between the ninth and eleventh ribs in the left midaxillary line 4. A dull percussion note in the left upper quadrant at the midclavicular line

ANS: 2 Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (option 4).

The nurse knows that during an abdominal assessment, deep palpation is used to determine: 1. bowel motility. 2. enlarged organs. 3. superficial tenderness. 4. overall impression of skin surface and superficial musculature.

ANS: 2 With deep palpation, note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

The nurse notes that a patient has had a black, tarry stool and recalls that a possible cause would be: 1. gallbladder disease. 2. overuse of laxatives. 3. gastrointestinal bleeding. 4. localized bleeding around the anus.

ANS: 3 Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Red blood in stools occurs with localized bleeding around the anus.

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: 1. aphasia. 2. dysphasia. 3. dysphagia. 4. myophagia.

ANS: 3 Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing.

Which of the following statements is true regarding an aortic aneurysm? 1. A bruit is absent. 2. Femoral pulses are increased. 3. A pulsating mass is usually present. 4. Most are located below the umbilicus.

ANS: 3 Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: 1. pulsations of the renal arteries. 2. pulsations of the inferior vena cava. 3. normal abdominal aortic pulsations. 4. increased peristalsis from a bowel obstruction.

ANS: 3 Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.

Percussion notes heard during the abdominal assessment may include: 1. flatness, resonance, and dullness. 2. resonance, dullness, and tympany. 3. tympany, hyperresonance, and dullness. 4. resonance, hyperresonance, and flatness.

ANS: 3 Percussion notes normally heard during the abdominal assessment may include 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 distention; and dullness, which may be palpated over a distended bladder or enlarged spleen or liver.

A patient is complaining of tenderness along the costovertebral angles. The nurse knows that this symptom is most often indicative of: 1. ovary infection. 2. liver enlargement. 3. kidney inflammation. 4. spleen enlargement.

ANS: 3 Tenderness along the costovertebral angles occurs with inflammation of the kidney or paranephric area.

Tenderness on light palpation in the right lower quadrant could indicate a disorder of which of the following structures? 1. Spleen 2. Sigmoid 3. Appendix 4. Gallbladder

ANS: 3 The appendix is located in the right lower quadrant and when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant.

A patient's abdomen is bulging and stretched in appearance. The nurse would describe this finding as: 1. obese. 2. herniated. 3. scaphoid. 4. protuberant.

ANS: 4 A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7.

The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is: 1. increased salivation. 2. decreased peristalsis. 3. increased esophageal emptying. 4. decreased gastric acid secretion.

ANS: 4 As one ages, salivation decreases, esophageal emptying is delayed, and peristalsis is thought to remain fairly constant. Gastric acid secretion decreases with aging. Decreased peristalsis may result from decreased bulk in diet, decreased fluid intake, or laxative abuse.

The physician comments that a patient has abdominal "borborygmi." The nurse knows that this term refers to: 1. a loud continuous hum. 2. a peritoneal friction rub. 3. hypoactive bowel sounds. 4. hyperactive bowel sounds.

ANS: 4 Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.

To the horizontal plane, a scaphoid contour of the abdomen depicts: 1. a flat profile. 2. a convex profile. 3. a bulging profile. 4. a concave profile.

ANS: 4 Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane.

To detect diastasis recti, the nurse should have the patient perform which of the following maneuvers? 1. Relax in the supine position. 2. Raise arms in the left lateral position. 3. Raise arms over the head while supine. 4. Raise the head while remaining supine.

ANS: 4 Diastasis recti is a separation of the abdominal rectus muscles, which can congenitally, as a result of pregnancy, or from marked obesity. This is assessed by having the patient raise the head while remaining supine.

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? 1. Percuss and palpate in the lumbar region. 2. Inspect and palpate in the epigastric region. 3. Auscultate and percuss in the inguinal region. 4. Percuss and palpate the midline area above the suprapubic bone.

ANS: 4 Dull percussion sounds would be elicited over a distended bladder, and the *hypogastric area* would seem firm to palpation.

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 the following is true regarding assessment of the spleen in this situation? 1. The spleen can be enlarged as a result of trauma. 2. The spleen is normally felt upon routine palpation. 3. If an enlarged spleen is noted, palpate thoroughly to determine size. 4. An enlarged spleen should not be palpated because it can rupture easily.

ANS: 4 If you feel an enlarged spleen, refer the person but do not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation.

Which structure is located in the left lower quadrant of the abdomen? 1. Liver 2. Duodenum 3. Gallbladder 4. Sigmoid colon

ANS: 4 The sigmoid colon is located in the left lower quadrant of the abdomen.

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 quadrant

ANS: A A large amount of ascitic fluid produces a dull sound to percussion.

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

ANS: A The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.

35. During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to: a. Enlarged liver. b. Enlarged spleen. c. Distended bowel. d. Excessive diarrhea.

ANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

30. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. "No need to worry. Most men your age develop hernias." b. "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." c. "A hernia is the result of prenatal growth abnormalities that are just now causing problems." d. "I'll have to have your physician explain this to you."

ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall.

38. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds.

ANS: B The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

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

ANS: B, D 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.

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

ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may 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.

36. During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? a. Intra-abdominal bleeding b. Constipation c. Umbilical hernia d. Abdominal tumor

ANS: C The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

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.

ANS: D A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.

37. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a. Splenomegaly. b. Distended bladder. c. Constipation. d. Ascites.

ANS: D If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.

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

ANS: D Peptic ulcer disease occurs with the frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infection.

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

Ans A A recent study found estimates of lactose-intolerance prevalence as follows: 19.5% for Blacks, 10% for Hispanics, and 7.72% for Whites.