Jensen - Ch. 20
A nurse observes 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?"
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit
A nurse examines a client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of the client's abdomen?
Absent
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?
Absent
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
A client complains of a burning sensation in the esophagus after eating. Which associated condition should the nurse most suspect?
Acid reflux
A 26-year-old sports store manager comes to the clinic with severe right-sided abdominal pain for 12 hours. He began having a stomach ache yesterday with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 38.8° and his heart rate is 170. His bowel sounds are decreased, and he has rebound and involuntary guarding at one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain?
Acute appendicitis
Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause?
An enlarged liver felt during palpation
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
A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem?
Visible peristaltic waves
The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible
paralytic ileus.
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?
Abdominal aortic aneurysm
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?"
A 49-year-old woman has visited the clinic with complaints of excessive flatus and bloating, symptoms that are causing her both discomfort and embarrassment. Which of the following questions should the nurse ask the client during assessment of the health problem?
"Do you find that any particular foods, like dairy, make the problem worse?"
The peritoneum is a serous membrane that contains which of the following?
A parietal layer
A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend?
Avoid excessive alcohol intake
While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound?
Borborygmus
When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding?
Bowel sounds normal
The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what?
Bruit
A college student presents to the health care clinic with reports no bowel movement for four (4) days, bloating, and generalized abdominal discomfort. She states she has not been eating and drinking correctly and is stressed because she has a final exam in two (2) days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants, tenderness in the left lower quadrant with a few small round, firm masses. Rovsing's sign and the Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client?
Constipation related to decrease in fluid intake
The nurse assess for kidney tenderness at what location?
Costovertebral angle
Why is the appearance of urine important to evaluate during an abdominal examination?
Dark urine may be from dehydration
Older adults often have trouble with swallowing. What might cause this?
Decreased saliva production
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
Which additional health history question related to the abdominal system is appropriate for people of African American decent?
Do you or your parents have sickle cell disease or trait?
Sequence the steps of the physical examination of the abdomen in the order the nurse should follow. All options must be used.
Drape the client. Ask the client about pain. Warm hands and membrane of stethoscope. Stand at the client's right side. Begin palpation, auscultation, and percussion.
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?
Dullness
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?
Family history; dietary habits
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
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
A 23-year-old man has recently graduated from university and is preparing to embark on a backpacking trip around Southeast Asia. In preparation for his trip, the client has visited a clinic to obtain vaccinations. The client will be able to obtain vaccines protecting against which of the following?
Hepatitis A and B
A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?
Inspect, auscultate, percuss, palpate
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?
Inspect, auscultate, percuss, palpate
When performing the abdominal assessment for a client, which assessment technique should the nurse perform first?
Inspection
A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm 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
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
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
A 21-year-old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology?
Irritable bowel syndrome
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
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.
The nurse performs the technique shown when assessing a client. For what is this nurse assessing?
Kidney tenderness
The nurse is assessing an older adult client for severe malnutrition. Which of the following factors increases this client's risk for malnutrition?
Limited access to a grocery store
A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following?
Linea alba
A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse?
Listen for a total of 5 minutes
A nurse auscultates for bowels sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after one minute. What is an appropriate action by the nurse?
Listen for a total of five (5) minutes
The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?
Listen for five minutes before documenting an absence of bowel sounds.
The nurse is palpating in the right upper abdominal quadrant and feels and enlarged area. The nurse recognizes that she is most likely feeling what organ?
Liver
The nurse performs the assessment technique shown. What is the nurse assessing in this client?
Liver size
The nurse assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C (99.3°F;). Which of the following interventions is appropriate for this client?
Monitor pulse and blood pressure every 15 minutes until stable
You are assessing a patient for acute cholecystitis. What sign would you assess for?
Murphy sign
The nurse is assessing an adult client with right lower quadrant abdominal pain. The client has no history of prior surgeries, has no allergies, and is physically fit. Which of the following should the nurse do during the abdominal examination?
Observe the client's face for signs of discomfort
Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure?
Overflow incontinence
A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?
Spleen
A nurse assesses a client with a distended abdomen. Which action by the nurse demonstrates the correct way to assess the client for ascites?
Percuss the flanks from bed upward toward the umbilicus
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.
To promote relaxation of the client's abdominal muscles, what would be most appropriate for the nurse to do?
Place a pillow under both of the client's knees.
A nurse is attempting to palpate the abdomen of a 6-year-old girl, but the girl is so ticklish that the nurse cannot proceed. Which of the following should the nurse do?
Place the client's hand under the nurse's hand for a few moments
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
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?
Positive Rovsing's sign
When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant?
Right kidney, ascending colon, and liver
During the abdominal examination, a nurse hyperextends a client's right leg. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign?
Psoas
When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)
Psoas sign Rovsing sign Cutaneous hyperesthesia
The client would complain of pain in what quadrant if experiencing appendicitis?
RLQ
The nurse correctly identifies the gallbladder is located where?
RUQ
The nurse plans to assess a client's liver border. Which area of the abdomen is the nurse going to assess?
RUQ
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
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?
Right lower quadrant
As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located?
Right upper quadrant
Which nursing diagnosis is most appropriate for an elderly client with poor dentition?
Risk for Imbalanced Nutrition: Less Than Body Requirements
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?
Spleen
When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach.
True
The nurse understands this abdominal organ is responsible for storing red blood cells and platelets.
Spleen
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
Which of the following would a nurse suspect if dullness is percussed at the last interspace at the anterior axillary line on deep inspiration?
Splenomegaly
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.
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?
Stop palpating and get medical assistance.
When inspecting the abdomen, which of the following client positions facilitates correct examination technique?
Supine with arms at sides or folded across chest
The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?
Suprapubic
The nurse is preparing to palpate the client's spleen. What should the nurse instruct the client to do?
Take a deep breath and exhale
Which of the following statements provides the most accurate guide to the assessment of the gallbladder?
The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.
The nurse is assessing a client's abdomen as shown. Which technique is the nurse using?
Two-handed deep palpation
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
A client reports severe pain in the left lower quadrant of three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history?
The left lower quadrant is palpated last
While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen?
To identify bowel sounds
Rovsing's sign is a test of referred rebound tenderness in appendicitis.
True
The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area?
auscultation
The nurse is taking the health history of a client who takes a calcium channel blocking medication for hypertension. The client reports a sensation of incomplete evacuation when having a bowel movement about three times per week. For which problem should the nurse further assess the client?
constipation
The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the
costovertebral angle.
The nurse notes guarding while palpating the abdomen of a newly admitted patient despite asking the patient to try to relax. The nurse should (Select all that apply.)
distract the patient with conversation have the patient mouth breathe with the jaw dropped open assess relaxation of abdominal muscle after the patient exhales
The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation?
identify abdominal organs
The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first
inspect the abdominal area.
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the
left upper quadrant.
A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness?
light palpation
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should
palpate deeply while quickly releasing pressure.
A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment?
place a small pillow under the client's knees
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's
right upper quadrant.
A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of
stomach ulcers.
While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible
umbilical hernia.
A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition?
viral hepatitis
A nurse is assessing a client with a history of alcohol abuse. The client reports right upper quadrant pain. Which type of pain is the client experiencing?
visceral
