prep U chapter 23
The peritoneum is a serous membrane that contains which of the following?
A parietal layer
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?
Abdominal aortic aneurysm
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit
Which finding obtained during the abdominal assessment in an older adult client should prompt the nurse to perform an additional assessment to determine the cause?
An enlarged liver felt during palpation
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
The nurse is performing an assessment on a client that is on postop day 2. The abdominal wound has pulled apart and the contents are spilling out. The nurse recognizes this as a what?
Dehiscence
Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?
Flex the client's legs by placing a pillow under the knees
What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen?
Hypogastric
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 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 cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement?
Measure abdominal girth
Where is the linea alba located?
Middle of the ventral abdominal wall
During the abdominal examination, a nurse supports the client's right knee and ankle. The nurse flexes the client's hip and rotates the leg externally and internally. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign?
Obturator
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
The client would complain of pain in what quadrant if experiencing appendicitis?
RLQ
The nurse is caring for a client being treated for a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part?
Small intestine
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
The nurse percusses the lowest interface in the left anterior axillary line, asks the client to take a deep breath, and percusses again. The nurse is assessing for which of the following?
Splenic percussion sign
The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?
Suprapubic
The pancreas of an adult client is located
deep in the upper abdomen and is not normally palpable.
The nurse is caring for a female client during her first postoperative day after a temporary colostomy. The client refuses to look at the colostomy bag or the area. A priority nursing diagnosis for this client is
disturbed body image related to temporary colostomy.
A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness?
light palpation
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
During an assessment, the client describes vomiting moderate amounts that "smell like poop." The nurse might suspect
small bowel obstruction
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 presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action?
Ask the client when the pain began.
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
An older client presents with symptoms of pain on urinating. The nurse recognizes that older adults are at increased risk for urinary tract infections for which of the following reasons?
Decreased activity of protective bacteria in the urinary tract
On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity?
Fluid accumulation
The nurse performs the assessment technique shown. What is the nurse assessing in this client?
Liver size
How should the nurse perform blunt percussion over the liver?
Place left hand on right lower rib cage, strike it with ulnar side of right fist
The nurse correctly identifies the gallbladder is located where?
RUQ
The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should
ask the client to empty his bladder.
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 is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible
internal bleeding.
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?"