Deck 19: Abdomen

Question 1

The nurse is completing discharge instructions for a client admitted with esophagitis.Which of the following statements by the client indicate that the client requires further education?
1)"I'm going to talk to my doctor about a nicotine patch."
2)"I can do all of this stuff you're talking about as long as I don't have to give up my beer."
3)"I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle."
4)"The root of this problem is that I just sleep too much."
5)"I told my wife to stop making serving me all of those vegetables."

Answer 1

2,4,5

Question 2

The nurse is preparing to perform an abdominal assessment.The client states,"Can you point to where my appendix is located?" Draw an arrow to the location of the client's appendix.

Answer 2

Question 3

The client states,"No one will let me eat or drink anything until after my test and it's been 9 hours since I last ate anything!" While auscultating the client's abdomen the nurse hears frequent bowel sounds.In which of the following ways should the nurse accurately document this finding?
1)Borborygmi present
2)Hypoactive bowel sounds present
3)Bruit present
4)Friction rub present

Answer 3

1

Question 4

The nurse is performing a focused interview with a 79-year-old client.Which of the following statements by the client is unexpected?
1)"I have been having loose stools every day for the last 3 years."
2)"I know I just don't drink as much water as I should."
3)"My belly seems softer and flabbier as I get older."
4)"My mouth is always dry."

Question 5

The nurse is performing an abdominal assessment.After percussing the abdomen,the nurse notes that the liver span is approximately 9 centimeters.Which of the following ways is an appropriate way to document this finding?
1)Hepatomegaly
2)A normal finding
3)Related to recent diagnosis of chronic bronchitis
4)Presence of ascites

Question 6

The nurse is documenting the findings of an abdominal assessment on a client and documents the following information,"pain noted during palpation at McBurney's point." In which of the following ways did the nurse elicit this response?
1)The nurse lightly palpated the around the client's umbilicus.
2)The nurse pressed into the client's abdomen and then pulled his hand back quickly.
3)The nurse palpated over the client's spleen.
4)The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.

Question 7

The client was recently admitted to the hospital with left lower quadrant pain.The client states,"It feels like my belly is cramping." Guarding is noted during the abdominal examination.During the focused interview,the client admitted to experiencing a significant amount of occupational stress.The nurse reviews the information included in the chart above and determines that the client has developed a specific condition.Which of the following statements by the client is most consistent with this condition?
1)"I get home so late at night,but I've got to stop lying down right after dinner."
2)"I drink a whole pot of coffee every day."
3)"I drink 9-12 beers after I get home from work,every day."
4)"We have been growing green beans in our garden and I think I ate too many the other day."

Question 8

A client asks the nurse,"What's the purpose of a gall bladder anyway? My mom lived for many years without her gallbladder after she had to have it taken out." Which of the following information would be beneficial for the nurse to share with this client?
1)"You are right.We still don't know the function of the gallbladder."
2)"It stores bile until it is needed for digestion of fats."
3)"It destroys old red blood cells."
4)"It helps you digest carbohydrates by producing enzymes."

Question 9

The nurse is speaking with the client during the focused interview.The client states,"My doctor said that my spleen was enlarged.Where is my spleen?" Draw an arrow to the location of the spleen.

Question 10

The nurse is performing an abdominal assessment on a client.While the nurse is palpating the lower border of the liver,the nurse asks the client to take a deep breath and hold it.The client complains of a sharp pain located in the right upper quadrant.In which of the following ways would the nurse accurately document this finding?
1)Positive Blumberg's sign
2)Presence of pain at McBurney's point
3)Positive Murphy's sign
4)Positive Psoas sign

Question 11

The nurse is palpating the left upper quadrant of a client's abdomen.Which of the following organs may be assessed during this portion of the assessment?
1)Liver
2)Gallbladder
3)Appendix
4)Spleen
5)Stomach

Question 12

The nurse is assessing the client's abdomen and notes dullness when percussing over the left lower quadrant.Which of the following questions is most appropriate for the nurse to ask the client at this time?
1)"How much alcohol do you drink?"
2)"Do you have pain after eating?"
3)"When was your last bowel movement?"
4)"Have you ever had splenomegaly?"

Question 13

The nurse is assessing a client in the Emergency Department with complaints of right lower quadrant pain.The nurse determines that the client is exhibiting a positive psoas sign.The nurse accurately suspects that which of the following conditions or problems may be occurring?
1)Constipation
2)Appendicitis
3)Cholecystitis
4)Small bowel obstruction
5)Peritonitis

Question 14

The nurse is mapping the client's abdomen into four quadrants.Which of the following landmarks would the nurse use to perform this assessment?
1)Umbilicus
2)Midclavicular lines
3)Xiphoid process
4)Lower border of the right ribs
5)Iliac crests

Question 15

The nurse is palpating the right upper quadrant of a client's abdomen.Which of the following organs may be assessed during this portion of the assessment?
1)Liver
2)Gallbladder
3)Appendix
4)Spleen
5)Stomach

Question 16

The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back.The client states,"This has been happening more often after I eat rich,high-fat foods." The nurse would suspect which of the following?
1)Cholecystitis
2)Duodenal ulcer
3)Gastritis
4)Pancreatitis

Question 17

The student nurse is preparing to examine a client who is complaining of left lower quadrant abdominal pain.The experienced nurse is observing the student nurse's abdominal assessment.Which of the following statements by the student nurse would indicate that the student nurse requires further education?
1)"It is a little cool in our examination room;may I turn up the thermostat?"
2)"I've been told you are experiencing some pain in the lower left area of your abdomen.I will examine that area first."
3)"I am going to stand on your left side so I can feel your liver better."
4)"I'm going to place this drape over you so you don't feel too exposed during this examination."
5)"I am going to place this pillow behind your head and this pillow under your knees."

Question 18

The nurse is performing an abdominal assessment on a client.During the focused interview,the client stated that he had been experiencing some abdominal pain.As the nurse assesses the client,which of the following behaviors indicates that the client may be experiencing pain or anxiety during the examination?
1)The client's respiratory rate is 26 per minute.
2)The client moves away from the nurse's hands.
3)The client grimaces.
4)The client pulls his knees toward his stomach.
5)The client coughs loudly.

Question 19

A client asks the nurse,"What's the purpose of the liver?" Which of the following statements would be beneficial for the nurse to share with the client?
1)"It helps you digest fats."
2)"It is an endocrine and exocrine gland."
3)"It filters waste from the blood and makes urine."
4)"It makes some blood clotting substances."
5)"It can help you store certain vitamins."

Question 20

The nurse is completing an abdominal assessment and is percussing over the left side of the upper portion of the client's abdomen over the area of the stomach.The client states,"I haven't had my breakfast,yet." The nurse would expect to find which of the following during this part of the examination?
1)Dullness
2)Flatness
3)Tympany
4)Hyperesonance

Question 21

The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis.As the nurse inspected the client's abdomen,the nurse suspected that the client had developed ascites.The nurse would perform which of the following nursing interventions as a result of this finding?
1)Obtain stool specimen for occult blood.
2)Measure the client's abdominal girth.
3)Obtain stool specimen for culture and sensitivity.
4)Bilateral leg measurements.
5)Percuss the abdomen at midline.

Question 22

The student nurses are preparing educational presentations regarding the Healthy People 2020 objectives.The nursing instructor is reviewing the topics of their presentations.Which of the following topics are appropriate and related to the objectives?
1)Educate pregnant women regarding the importance of small,more frequent dry meals throughout the day to reduce nausea and vomiting.
2)Educate Asian men about the importance of avoiding alcohol because this is a population that is prone to alcohol abuse.
3)Educate people who are anticipating traveling to India,Asia,Africa,or Central America about ways to reduce their risk of becoming infected with hepatitis E virus.
4)Educate immunocompromised populations and those caring for them about the importance of safe food handling.
5)Educate people about the relationship between regular,thorough oral hygiene practices and good nutrition.

Question 23

The nurse is interviewing a 79-year-old Hispanic client with complaints of recent weight loss,anorexia,and epigastric pain.The client reports recent use of "mints" for stomach upset.Which of the following interventions are appropriate?
1)Schedule the client for an endoscopy as ordered.
2)Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider.
3)Educate the client regarding Helicobacter pylori infections.
4)Discuss the importance of using over-the-counter aspirin for mild pain relief.
5)Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer.

Question 24

The nurse is caring for a client with hepatitis A virus.The client requests information about how the virus is transmitted.Which of the following statements by the nurse is the best response?
1)"This virus is transmitted by sexual contact with someone who already has been infected with this virus."
2)Most likely,you ate something that was contaminated with the virus."
3)"It is spread by blood transfusions."
4)"Have you ever injected an illegal drug?"

Question 25

The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the stethoscope.The nurse hears a soft,continuous humming sound.The nurse suspects that dysfunction of which of the following organs ultimately may have resulted in the production of this sound?
1)Stomach
2)Spleen
3)Pancreas
4)Liver

Question 26

The nurse is performing an abdominal assessment on an infant.The nurse notes that the umbilicus is bulging and has been displaced slightly to the left of midline.The nurse would suspect that the infant has developed which of the following conditions?
1)Infection
2)Umbilical hernia
3)Ventral hernia
4)Hiatal hernia

Question 27

The client's ideal body weight is 125 pounds.The nurse is calculating the client's weight in order to determine if the client is obese.The client weighs 155.5 kilograms.Calculate the client's weight in pounds.Round to the nearest whole number.
______ pounds

Question 28

The client is 14 years old and is visiting the healthcare provider's office with abdominal pain.The client states,"The pain is sort of all over my belly.I can't really find one place that hurts more than another area." Based on the nurse's understanding about disorders of abdomen and associated symptomatology,the nurse will expect to discover that which of the following nursing diagnoses can most likely be applied to this client's plan of care?
1)Acute pain
2)Hypothermia
3)Diarrhea
4)Altered urinary elimination
5)Altered nutrition,less than body requirements

Question 29

The pediatric nurse is preparing an educational presentation for parents of school-aged children regarding hepatitis.The nurse wishes to focus on the most common type that occurs in children.Which of the following types of hepatitis viruses would the nurse choose to focus on during this presentation?
1)Hepatitis A virus
2)Hepatitis B virus
3)Hepatitis C virus
4)Hepatitis D virus

Question 30

The nurse is performing an abdominal assessment on the client.Rank the following steps of assessment in the order that they should be performed.
1)Percuss the abdomen. Choice
2)Visualize the quadrants of the abdomen. Choice
3)Palpate the abdomen. Choice
4)Auscultate the abdomen. Choice
5)Encourage the client to void.