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Abdomen Assessment > Abdomen > Flashcards

Abdomen Flashcards

1
Q

Explain where one might hear tympani and dullness when percussing the abdomen

A

Tympani in all 4 quadrants – normal sound

Dullness over RUQ - high under costal margin – liver

Resonance ONLY in lung fields

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2
Q

Explain how to percuss the liver span and spleen. What is normal?

A

Hold breath or let out all breath – (liver moves) and percuss downward at L Mid clavicular line – area of dullness Is measured – 5-10 cm (women smaller than men)

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3
Q

How are the fluid wave and shifting dullness tests performed? What do they indicate?

A

Fluid wave – push on one side of patient’s abdomen – with patient supine – put patient hand in middle and feel wave (if there is fluid) on other side of abdomen.. if not fluid but fat, the patient hand will stop the “wave” - Shifting dullness – percuss as patient is supine from tympani to dullness then have lay on side and do same. IF fluid, the fluid shifts and dullness shifts - both indicate ascites = 3rd space or extracell. Spacing of fluid from VEINS and PROTEIN which pulls more fluid from the veins = edema

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4
Q

What are the differences between light and deep palpation? What are the purposes of each?

A

Light for superficial masses, muscle tone, symmetry, pain

Deep palpation for organomegaly

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5
Q

What is rebound tenderness? IF + = peritoneal inflammation

A

Done by pushing into abdomen and quickly bringing hands up – the reflexive bounce causes peritoneal spasm – PAIN if inflamed = +Blumbergs test

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6
Q

What examination findings would you expect with each condition?

Obesity

A

Protruberant abdomen with negative fluid wave- probable striae

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7
Q

What examination findings would you expect with each condition?

Ascites

A

+ fluid wave and shifting dullness and history of liver or cancer issue –
See LOW albumin in their blood levels – other edema?

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8
Q

What examination findings would you expect with each condition?

Gaseous distention

A

tons of tympani with a distended abdomen – common with ileus where intestinal motility stops/slows and gas-producing bacteria is hanging in one place of intestine.

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9
Q

What examination findings would you expect with each condition?

Tumor

A

area of organomegaly or mass palpable with deep palpation – dullness on percussion

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10
Q

What tests are done for a person with suspected appendicitis?

A

Psoas – right leg lift -

Obturator – bent R leg – ab and adducted

Rebound – Blumbergs – peritoneal irritation/perforation
+White blood count – Ultrasound – CT

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11
Q

What tests are done for a person with suspected cholecystitis?

A

Murphy – palpation of gallbladder with the inhalation of breath – liver moves up – fingers touch gallbladder - + liver function tests and ultrasound for stones

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12
Q

What are the symptoms of Crohns and Ulcerative colitis?

A 
Bloody
mucousy, 
diarrhea, 
bloating, 
gas, 
urgency to have stool – 
abdominal pain  - 
may have anal and rectal ulcers
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13
Q

What does it mean to have melena (black, tarry stools) or Bright red blood per stool?

A

Melena – black tarry stools are sign of blood that HAS been digested by HCL acid (stomach) or upper GI

Bright red blood in stool has NOT been digested – lower GI tract – hemorrhoids

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14
Q

What are some signs of internal abdominal bleeding?

A 
Cullen, 
Grey Turner Flank, 
HYPOTENSION, 
TACHYCARDIA, 
low blood count, 
shock (poor perfusion)  and 
rebound tenderness
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15
Q

Which structure is located in the left lower quadrant of the abdomen?

  1. Liver
  2. Duodenum
  3. Gallbladder
  4. Sigmoid colon
A

Sigmoid colon

The sigmoid colon is located in the left lower quadrant of the abdomen.

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16
Q

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:

  1. aphasia.
  2. dysphasia.
  3. dysphagia.
  4. myophagia.
A

Dysphagia

Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing

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17
Q

The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is:

  1. increased salivation.
  2. decreased peristalsis.
  3. increased esophageal emptying.
  4. decreased gastric acid secretion.
A

decreased gastric acid secretion.

As one ages, salivation decreases, esophageal emptying is delayed, and peristalsis is thought to remain fairly constant. Gastric acid secretion decreases with aging. Decreased peristalsis may result from decreased bulk in diet, decreased fluid intake, or laxative abuse.

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18
Q

A patient s abdomen is bulging and stretched in appearance. The nurse would describe this finding as:

  1. obese.
  2. herniated.
  3. scaphoid.
  4. protuberant.
A

protuberant

A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7.

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19
Q

The nurse notes that a patient has had a black, tarry stool and recalls that a possible cause would be:

  1. gallbladder disease.
  2. overuse of laxatives.
  3. gastrointestinal bleeding.
  4. localized bleeding around the anus.
A

gastrointestinal bleeding.

Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Red blood in stools occurs with localized bleeding around the anus.

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20
Q

Which of the following statements is true regarding an aortic aneurysm?

  1. A bruit is absent.
  2. Femoral pulses are increased.
  3. A pulsating mass is usually present.
  4. Most are located below the umbilicus.
A
  1. A pulsating mass is usually present

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.

21
Q

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient s abdomen. Before reporting this finding as silent bowel sounds the nurse should listen for at least:

  1. 1 minute.
  2. 5 minutes.
  3. 10 minutes.
  4. 2 minutes in each quadrant.
A
  1. 5/five minutes

Absent bowel sounds are rare. The nurse must listen for 5 minutes by the watch before deciding bowel sounds are completely absent.

22
Q

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse will conduct which of the following to assess for this condition?

  1. Obturator test
  2. Murphy s sign
  3. Assess for rebound tenderness
  4. Iliopsoas muscle test
A
  1. Murphy’s sign

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. The person feels sharp pain and abruptly stops inspiration midway.

23
Q

A 40-year-old man states that his doctor told him that he has a hernia. He asks the nurse to explain what a hernia is. Which action by the nurse is appropriate?

  1. Tell him not to worry, that most men his age develop hernias.
  2. Refer him to his physician for additional consultation because he or she made the initial diagnosis.
  3. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.
  4. Explain that hernias that occur in adulthood are often the result of prenatal growth abnormalities.
A
  1. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

A hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall.

24
Q

During report, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to a/an:

  1. enlarged liver.
  2. enlarged spleen.
  3. distended bowels.
  4. excessive diarrhea.
A
  1. enlarged liver

The term hepatomegaly refers to an enlarged liver.

25
Q

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:

  1. splenomegaly.
  2. distended bladder.
  3. constipation.
  4. ascites.
A
  1. Ascites

If ascites (fluid in the abdomen) is present, the examiner will feel a fluid wave when assessing the abdomen.

26
Q

The nurse suspects that a patient has appendicitis. Which of the following procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.

1 Murphy’s sign

  1. Blumberg s sign
  2. Obturator test
  3. Iliopsoas muscle test
A
  1. Blumberg’s sign
  2. Obutrator test
  3. Iliopsoas muscle test

Blumberg s sign (rebound tenderness), the iliopsoas muscle test, and the obturator test should be used to assess for appendicitis. Murphy s sign is used to assess for an inflamed gallbladder or cholecystitis.

27
Q
  1. Select the sequence of techniques used during an examination of the abdomen.

a. percussion, inspection, palpation, auscultation
b. inspection, palpation, percussion, auscultation
c. inspection, auscultation, percussion, palpation
d. auscultation, inspection, palpation, percussion

A

c. inspection, auscultation, percussion, palpation

28
Q
  1. Which of the following may be noted through inspection of the abdomen?

a. fluid waves and abdominal contour
b. umbilical eversion and Murphy’s sign
c. venous pattern, peristaltic waves, and abdominal contour
d. peritoneal irritation, general tympany, and peristaltic waves

A

c. venous pattern, peristaltic waves, and abdominal contour

29
Q
  1. Right upper quadrant tenderness may indicate pathology in the:

a. liver, pancreas, or ascending colon
b. liver and stomach
c. sigmoid colon, spleen, or rectum
d. appendix or ileocecal valve

A

a. liver, pancreas, or ascending colon

30
Q
  1. Hyperactive bowel sounds are:

a. High pitched
b. Rushing
c. Tinkling
d. All of the above

A

d. All of the above

31
Q
  1. The absence of bowel sounds is established after listening for:

a. 1 full minute
b. 3 full minutes
c. 5 full minutes
d. none of the above

A

c. 5 full minutes

32
Q
  1. Auscultation of the abdomen may reveal bruits of the ___ arteries.

a. aortic, renal, iliac, and femoral
b. jugular, aortic, carotid, and femoral
c. pulmonic, aortic, and portal
d. renal, iliac, internal jugular, and basilic

A

a. aortic, renal, iliac, and femoral

33
Q
  1. The range of normal liver span in the right midclavicular line in the adult is:

a. 2-6 cm
b. 4-8 cm
c. 8-14 cm
d. 6-12 cm

A

d. 6-12 cm

34
Q
  1. The left upper quadrant (LUQ) contains the:

a. liver
b. appendix
c. left ovary
d. spleen

A

d. spleen

35
Q
  1. Striae, which occur when the elastic fibers in the reticular layer of the skin are broken following rapid or prolonged stretching, have a distinct color when of long duration. This color is:

a. pink
b. blue
c. purple-blue
d. silvery white

A

d. silvery white

36
Q
  1. Auscultation of the abdomen is begun in the right lower quadrant (RLQ) because:

a. bowel sounds are always normaly present here
b. peristalsis through the descending colon is usually active
c. tis is the location of the pyloric sphincter
d. vascular sounds are best heard in this area

A

a. bowel sounds are always normaly present here

37
Q
  1. A dull percussion note forward of the left midaxillary line is:

a. normal, an expected finding during splenic percussion
b. expected between the 8th and 12th ribs
c. found if the examination follows a large meal
d. indicative of splenic enlargement

A

d. indicative of splenic enlargement

38
Q
  1. Shifting dullness is a test for:

a. Ascites
b. Splenic enlargement
c. Inflammation of the kidney
d. hepatomegaly

A

a. Ascites

39
Q
  1. Tenderness during abdominal palpation is expected when palpating:

a. the liver edge
b. the spleen
c. the sigmoid colon
d. the kidneys

A

c. the sigmoid colon

40
Q
  1. Murphy’s sign is best described as:

a. the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix
b. pain felt when taking a deep breath when the examiner’s fingers are on the approximate location of the inflamed gallbladder
c. a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle
d. not a valid examination technique

A

b. pain felt when taking a deep breath when the examiner’s fingers are on the approximate location of the inflamed gallbladder

41
Q

Ascites is defined as:
A. a bowel obstruction.
B. a proximal part of the large intestine.
C. an abnormal enlargement of the spleen.
D. an abnormal accumulation of serous fluid within the peritoneal cavity.

A

D. an abnormal accumulation of serous fluid within the peritoneal cavity.

42
Q

Pyloric stenosis is defined as a(n):
A. abnormal enlargement of the pyloric sphincter.
B. inflammation of the pyloric sphincter.
C. congenital narrowing of the pyloric sphincter.
D. None of the above

A

C. congenital narrowing of the pyloric sphincter.

43
Q 
Moles:
A. are common on the abdomen.
B. are uncommon on the abdomen.
C. always require a biopsy.
D. are no cause for concern.
A

A. are common on the abdomen.

44
Q 
The right upper quadrant of the abdomen contains which of the following organs?
A. Spleen
B. Liver
C. Cecum
D. Left ureter
A

B. Liver

45
Q 
Which of the following refers to the four layers of large, flat abdominal muscles?
A. Linea alba
B. Rectus abdominus
C. Ventral abdominal wall
D. None of the above
A

C. Ventral abdominal wall

46
Q

Pyrosis is defined as:
A. an inflammation of the peritoneum.
B. a burning sensation in the upper abdomen.
C. a congenital narrowing of the pyloric sphincter.
D. an abnormally sunken abdominal wall.

A

B. a burning sensation in the upper abdomen.

47
Q 
7. The abdomen normally moves when breathing until the age of \_\_\_\_ years.
A. 4
B. 7
C. 14
D. 75
A

B. 7

48
Q 
Which is true for aging adults?
A. Decreased salivation leads to dry mouth.
B. Gastric acid secretion increases.
C. Liver size increases.
D. None of the above
A

A. Decreased salivation leads to dry mouth.

Abdomen Assessment (1 decks)

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