Ch. 23 Abdomen – Flashcards
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When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach.
True or False?
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True
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A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says
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"I can decrease the constipation if I eat foods high in fiber and drink water."
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On inspection of abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes this finding is most likely due to what process occurring within the abdominal cavity?
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Fluid accumulation
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A student nurse is auscultating for bowels sounds on a client who returned from surgery 48 hours ago. The student tells the charge nurse that she cannot hear bowel sounds in the lower quadrants. What is the appropriate response by the charge nurse to this information?
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It takes 3-5 post surgery for bowl sounds to return completely.
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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?
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Avoid excessive alcohol intake
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A soft-pitched humming sound associated with partial obstruction of an artery and reduced blood flow to the organ.
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Venous Hum
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swishing sound that indicate turbulent blood flow
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bruit
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increased bowl sounds
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Borborygmi
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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?
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Appendicitis
Explanation:
This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.
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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?
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Helicobacter pylori
Explanation:
Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucous, on occasion the H. pylori disrupt the mucous lining and inflame the organ lining.
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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?
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Dehiscence
Explanation:
A wound dehiscence occurs when the incision opens and the contents spill out.
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Mrs. Wells presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that Mrs. Wells has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain?
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Dyspepsia
Explanation:
For more chronic symptoms, dyspepsia is defined as chronic or recurrent discomfort or pain centered in the upper abdomen.
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Right Upper Quadrant
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ascending and transverse colon
duodenum
gallbladder
liver
pancreas head
pylorus
right adrenal gland
right ureter
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Right Lower Quadrant
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appendix
ascending colon
cecum
right ovary
right ureter
right spermatic cord
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Left Upper Quadrant
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Left Kidney upper pole
left ureter
pancreas (body and tail)
spleen
stomach
transverse descending colon
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Left Lower Quadrant
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left kidney lower pole
left ovary and tube
left ureter
left spermatic cord
descending sigmoid colon
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Midline
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bladder
uterus
prostate gland
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To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the
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left upper quadrant
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A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?
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The gallbladder is located in the right upper quadrant of the abdomen. When it is inflamed (cholecystitis), performing the Murphy's sign will cause the client to hold the breath (inspiratory arrest).
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The nurse assess for kidney tenderness at what location?
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Costovertebral angle
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A client asks a nurse how to best decrease the risk of gallbladder cancer. Which statement by the nurse is appropriate?
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"A large gallstone in the common bile duct is the most common risk factor."
Explanation:
Women are affected with gallbalder cancer 2 ½ times more frequently than are men. Risk factors include gallstones, especially one large stone, or if a stone occurs before middle age. Other common risk factors include high parity, obesity, and abnormalities of the biliary system that cause chronic inflammation. Cigarette smoking is a risk factor but not the highest.
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The pancreas of an adult client is located
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deep in the upper abdomen and is not normally palpable.
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To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should
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raise the client's right leg from the hip.
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The sigmoid colon is located in this area of the abdomen
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left lower quadrant
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A nurse inspects a client's abdomen and notices that a bulge is present in the right lower quadrant. How should the nurse further assess this finding using inspection?
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Ask the client to raise the head off the bed
Explanation:
Asking the client to raise the head off the bed will help the nurse to determine the location of the mass. A mass within the abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is obscured.
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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?
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Absent
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The nurse understands this abdominal organ is responsible for storing red blood cells and platelets.
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Spleen
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How should the nurse perform blunt percussion over the liver?
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The correct way of performing blunt percussion is to place left hand on right lower rib cage, strike it with ulnar side of right fist. Placing the hand on the mid of rib cage would not enable the nurse to assess the liver.
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The nurse correctly identifies the gallbladder is located where?
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RUQ
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The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what?
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Appendicitis
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A nurse assesses a client with a distended abdomen. Which action by the nurse demonstrates the correct way to assess the client for ascites?
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Percuss the flanks from bed upward toward the umbilicus.
Auscultating for bowel sounds in all quadrants of abdomen may not give any indication about ascites.
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While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tingling sounds throughout the distended abdomen. The nurse should refer the client to a physician for possible
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intestinal obstruction
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The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should
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palpate deeply while quickly releasing pressure.
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During the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign?
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Murphy's
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Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen?
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Flex the client's legs by placing a pillow under the knees
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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?
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Crohn's disease
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The abdominal contents are enclosed externally by the abdominal wall musculature—three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external
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abdominal oblique.
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During the abdominal examination, a nurse performs deep palpation in the left lower quadrant. At this point, the client reports pain. This test is positive for which sign?
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Murphy's
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The colon originates in this abdominal area: the
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RLQ
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Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?
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Tympany that changes location with client position
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The nurse would assess for positive Blumberg sign how?
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Applying and releasing pressure to the abdomen
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The nurse auscultates 20 clicks and gurgles over 1 minute when examining a patient's abdomen. How should the nurse document this finding?
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normal bowl sounds
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The nurse assesses an adult male client's abdomen and observes diminished abdominal respiration. The nurse determines that the client should be further assessed for
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peritoneal irritation.
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To palpate for tenderness of an adult client's appendix, the nurse should begin the abdominal assessment at the client's
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RLQ
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What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?
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Place the tape measure behind the client and measure at the umbilicus
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The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by
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Cirrhosis and nephrosis
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Your patient has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for?
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Acute pancreatitis
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The nurse auscultates hyperactive bowel sounds in the ascending colon and absent bowel sounds in the descending colon. What is the nurse's best action?
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Tell client not to eat or drink anything.
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During the examination of the abdomen, a patient experiences right lower quadrant rebound tenderness. The nurse should do which additional assessment techniques for this patient?
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• Assess Rovsing's sign.
• Assess the psoas sign.
• Test for cutaneous hyperesthesia.
• Look for the obturator sign.
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A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?
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gastric ulcer
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The nurse explains to the client the main function of the stomach is to do what?
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store food
churn food
digest food
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The nurse is preparing to palpate the client's spleen. What should the nurse instruct the client to do?
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Take a deep breath and exhale
