The point chapter 20

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? "Before I get ready to examine the painful area, I will let you know in plenty of time." "Since you're having pain in a certain area, I won't have to do a very thorough exam there." "You don't need to worry about anything. I will make sure to be very gentle during the exam." "I'm going to examine the area where you're having pain first to get a better picture of what's going on."

"Before I get ready to examine the painful area, I will let you know in plenty of time.

The peritoneum is a serous membrane that contains which of the following? A parietal layer A visceral ligament Antibodies A drying agent

A parietal layer

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? Secreting digestive enzymes Absorbing large amounts of water Secreting bile Absorbing electrolytes

Absorbing large amounts of water

A 27-year-old woman comes to the emergency department reporting severe right lower quadrant pain. Her temperature is 101.5°F (38.6°C), BP 122/80 mm Hg, pulse 95 beats/min, and respirations 22 breaths/min. What might the nurse suspect the client has? Chronic gall bladder disease Hepatitis A Gastric cancer Acute appendicitis

Acute appendicitis

The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? Kidney pain Inflammation of the gallbladder Appendicitis Liver engorgement

Appendicitis

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 taking antacid medications Avoid taking pain medications with food Avoid eating overcooked foods Avoid excessive alcohol intake

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 Absent Hypoactive Erratic

Borborygmus

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

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? Risk for Fluid Volume Deficit Ineffective Nutrition: Less Than Body Requirements Ineffective Health Maintenance Constipation related to decrease in fluid intake

Constipation related to decrease in fluid intake

A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? Gastroesophageal reflux Pancreatitis Crohn's disease Gastric ulcer

Crohn's disease

When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize? Social patterns; past medical history Dietary habits; social patterns Surgical history; family history Family history; dietary habits

Family history; dietary habits

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? Bleeding Fluid accumulation Obstruction Inflammation

Fluid accumulation

A nurse observes the abdomen of a client and notices it to be distended below the umbilicus. The nurse recognizes that this can be caused by which of these conditions? Select all that apply. Full bladder Ovarian tumor Uterine enlargement Pancreatic mass Impacted colon Tumor of the kidney

Full bladder Uterine enlargement Ovarian tumor Impacted colon

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? Percuss, inspect, auscultate, palpate Palpate, percuss, inspect, auscultate Inspect, auscultate, percuss, palpate Auscultate, inspect, palpate, percuss

Inspect, auscultate, percuss, palpate

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? Peritonitis from a ruptured diverticulum Acute onset of appendicitis with possible rupture Internal adhesions from previous surgery Intestinal obstruction at the sigmoid colon

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? Internal abdominal oblique Linea alba Peritoneum Transverse abdominis

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? Assess for findings of dehydration Palpate for abdominal rigidity Document the absence of bowel sounds Listen for a total of 5 minutes

Listen for a total of 5 minutes

Which type of incontinence occurs when excessive bladder volume exceeds urethral pressure? Urge incontinence Stress incontinence Overflow incontinence Functional incontinence

Overflow incontinence

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 Positive skin hypersensitivity test Obturator sign Psoas sign

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 skin hypersensitivity test Psoas sign present Obturator sign positive Positive Rovsing's sign

Positive Rovsing's sign

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? Gallbladder Head of pancreas Liver Spleen

Spleen

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? Head of pancreas Spleen Gallbladder Liver

Spleen

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? Counsel the client regarding hernia repair. Provide a dietician consult for the client. Refer the client to an oncologist. Stop palpating and get medical assistance.

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. Refer the client to an oncologist. Provide a dietician consult for the client. Counsel the client regarding hernia repair.

Stop palpating and get medical assistance

When inspecting the abdomen, which of the following client positions facilitates correct examination technique? Sitting with hands on hips Supine with arms at sides or folded across chest Trendelenburg with hands over head Semi-Fowler's with pillows under head and knees

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? Upper abdomen Back Perineal Suprapubic

Suprapubic

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? Rub Hum Hollow tympanic notes Dullness

dullness

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? Gallbladder Kidneys Pancreas Stomach

gallbladder

The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation? discern muscular resistance identify abdominal organs complete a surface evaluation detect abdominal tenderness

identify abdominal organs

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the right upper quadrant. right lower quadrant. left upper quadrant. left lower quadrant.

left upper quadrant

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible masses. kidney trauma. cachexia. gallbladder disease.

masses

A client is experiencing left lower quadrant (LLQ) abdominal pain that radiates to the groin. Which health problem should the nurse suspect this client is experiencing? pelvic inflammatory disease ectopic pregnancy appendicitis renal stone

renal stone

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? right lower left lower left upper right upper

right upper

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 decreased gastric motility. abdominal tumors. stomach ulcers. pancreatic cancer.

stomach ulcers

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? alcohol hepatitis toxic liver damage viral hepatitis intrahepatic jaundice

viral hepatitis