Show Terms in this set (29)The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment? The nurse is planning a
physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment? Students also viewed1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Tympany ANS: B 2. Which structure is located in the left lower quadrant of the abdomen? a. Liver ANS: D The sigmoid colon is located in the left lower quadrant of the abdomen. The duodenum, or first part of the small intestine, and the gallbladder are located in the right upper abdominal quadrant. The sigmoid colon then is the structure that is located in the left lower abdominal quadrant. 3. A patient is having difficulty swallowing medications and food. How should the nurse document this? a. Aphasia ANS: D Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite. 4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region ANS: D The bladder is located in the suprapubic area (above the pubic bone) and if distended would elicit a dull sound when percussed and feel firm to palpation. However, this technique has been found to be unreliable and bedside bladder scanning with ultrasound is commonly used to estimate bladder volume. 5. The nurse is aware that what change may occur in the gastrointestinal system with aging? a. Increased salivation ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases. 6. 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 handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a. The spleen can be enlarged as a result of trauma. ANS: D If an enlarged spleen is felt, then the nurse should not continue to palpate it but refer the patient to a physician. An enlarged spleen is friable and can easily rupture with overpalpation 7. A patient's abdomen is bulging and stretched in appearance. How should the nurse document this finding? a. Obese ANS: D A bulging and stretched abdomen is described as protuberant. A protuberant abdomen is rounded, bulging, and stretched. A scaphoid abdomen caves inward. An obese abdomen appears uniformly rounded with a sunken umbilicus. A hernia is a protrusion of the abdominal viscera through an abnormal opening in the abdominal muscle wall. 8. The nurse is describing a scaphoid abdomen. When assessing the contour of the abdomen from the rib margin to the pubic bone, what would the contour look like? a. Flat ANS: D 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. The contour describes the nutritional state and normally ranges from flat to round. 9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. What does the nurse suspect? a. Pulsations of the renal arteries ANS: B Pulsations from the aorta are normally observed beneath the skin in the epigastric area, particularly in thin people who have good muscle wall relaxation. Pulsations of the renal arteries are not visible. The vena cava is a vein, not an artery, and does not have pulsations. Waves of peristalsis are sometimes visible in very thin people and appear as a slow ripple moving obliquely across the abdomen. 10. A patient has hypoactive bowel sounds. What is a possible cause of this finding? a. Diarrhea ANS: B Diminished or absent bowel sounds signal decreased gastrointestinal motility which can be caused from inflammation from peritonitis, a paralytic ileus after abdominal surgery, or with a bowel obstruction. Diarrhea, laxative use, and gastroenteritis cause hyperactive, not hypoactive, bowel sounds. 11. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a. "We need to determine the areas of tenderness before using percussion and palpation." ANS: B Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. 12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? a. Sound like two pieces of leather being rubbed together ANS: B Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine. 13. The physician comments that a patient has abdominal borborygmi. What is the best description of this term? a. Hypoactive bowel sounds ANS: C Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling. Upon auscultation borborygmi sounds like loud gurgling bowel sounds. 14. During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area ANS: B 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 (left upper quadrant at the midclavicular line). 15. The nurse is assessing the abdomen of a pregnant woman who states she has been having "acid indigestion" all the time. What does the nurse know that esophageal reflux during pregnancy can cause? a.
Diarrhea ANS: B Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct. 16. The nurse is performing an abdominal assessment. What types of percussion notes can be heard during abdominal assessment? a. Flatness, resonance, and dullness ANS: C 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 found over a distended bladder, adipose tissue, fluid, or a mass. Flatness is not a term used to describe a percussed sound. Resonance is a low-pitched, clear, hollow sound that predominates in healthy lung tissue but not in the abdomen. 17. An older patient has been diagnosed with pernicious anemia. This disorder could be r/t what condition? a. Increased gastric acid secretion ANS: B Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium. 18. A patient is reporting sharp pain along the costovertebral angles. What does this symptom most often indicate? a. Ovarian infection ANS: D Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct. Ovarian infection and liver or spleen enlargement do not cause pain along the costovertebral angles. 19. A nurse notices that a patient has abdominal ascites. What does this finding indicate? a. Flatus ANS: D Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer. 20. The nurse notices that a patient has had a black, tarry stool. What should the nurse recognize may cause this finding? a. Gallbladder disease ANS: C Stools may be black and tarry (melena) as a result of bleeding in the upper gastrointestinal tract. Red blood in stools occurs with localized bleeding in the rectal or anal areas. 21. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure? a. Spleen ANS: C The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant. The spleen is in the left upper quadrant; the sigmoid is in the left lower quadrant; and the gallbladder is in the right upper quadrant. 22. The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? a. Abdominal tone is increased. ANS: B In the older adult, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with an acute abdominal condition is less common in the aging person. The older adult with an acute abdominal condition often complains less about pain than the younger person. 23. During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this? a. Projectile vomiting ANS: A Significant 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. 24. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a. A bruit is absent. ANS: C 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. 25. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds? a. 1 minute ANS: B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent. 26. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test ANS: B 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 (Murphy test). The person feels sharp pain and abruptly stops midway during inspiration. The obturator and iliopsoas muscle tests assess for an inflamed appendix. Although a patient with cholecystitis may have rebound tenderness, the presence of rebound tenderness indicates peritoneal inflammation which could be caused by several things so it is not specific to cholecystitis. 27. Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a. "It should fall off in 10 to 14 days." ANS: A 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 in 10 to 14 days. Skin will cover the area in 3 to 4 weeks. 28. 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 ANS: A A large amount of ascitic fluid produces a dull sound to percussion. Flatness is not a term used to describe a percussed sound. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as with gaseous distention of the intestines in the abdomen, not with ascites or fluid. Tympany normally is the predominant sound heard on abdominal auscultation, but it is not heard with ascites, or fluid, in the abdomen. 29. 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." ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall. The nurse should acknowledge the patient's concerns and not tell him not to worry about it or refer him to his physician to explain it. It is not a result of prenatal growth abnormalities. 30. 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. How should the nurse proceed? a. Document the presence of hepatomegaly. ANS: C 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. 31. 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 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. 32. The nurse is reviewing information on lactose intolerance and learned that in some racial groups lactase activity (ability to digest and absorb lactose) is high at birth but declines to low levels by adulthood. Which ethnic group has the highest potential for lactose-intolerance symptoms in adulthood? a. Asians ANS: D Millions of American adults have the potential for lactose-intolerance symptoms; while 70-80% of White Americans produce lactase adequately into adulthood, only 30% of Mexican Americans, 20% of African Americans, and no American Indians will maintain adequate ability to digest lactose without adverse symptoms. 33. The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this disorder? a. Hypertension ANS: D Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the stomach or small intestine. The acid can create a painful open sore that may bleed. Peptic ulcers often occur with the frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infections all of which can cause inflammation and irritation to the stomach lining or mucosa. 34. During the change-of-shift report, the student nurse hears that a patient has hepatomegaly. What should the student recognizes that this term means? a. Enlarged liver ANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct. 35. 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. Constipation 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. 36. During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test? a. Ascites ANS: A 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. 37. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? a. Examine the tender area first. 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. 38. 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 ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may be relieved by eating more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis. 1. 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 fluid wave ANS: C, E 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. Why is auscultation done before percussion and palpation?Auscultating before the percussion and palpation of the abdomen ensures that the examiner is listening to undisturbed bowel sounds. In addition, if the patient is complaining of pain, leaving the palpation until last allows the examiner to gather other data before potentially causing the patient more discomfort.
Why should auscultation of the abdomen be performed before percussion and palpation of the abdomen?Take the history and perform inspection and auscultation before palpation, as this tends to put the patient at ease and increases cooperation. In addition, palpation may stimulate bowel activity and thus falsely increase bowel sounds if performed before auscultation.
What is the purpose of Percussing the abdomen?Percussion is a useful tool for evaluating abdominal tenderness. Lightly percuss the abdomen to determine the location of the pain. Localized pain is suggestive of peritoneal or intrabdominal inflammation, and is further discussed in the "Advanced Techniques" section.
When should you Auscultate the abdomen quizlet?Always auscultate the abdomen before palpating or percussing because touching can alter motility of the bowel and increase the sounds. Bowel sounds are created as air and fluid move. Normal bowel sounds are tinkling, gurgling noises that occur every 5 to 20 seconds.
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What is the reason that auscultation of the abdomen should be performed prior to percussion and palpation quizlet?
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