Chapter 22: Abdomen Flashcards
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which should should the nurse expect to hear?
a. Dullness
b. Tympany
c. Resonance
d. Hyperresonance
a. Dullness
RATIONALE: The liver is located in the right upper quadrant and would elicit a dull percussion note.
Which structure is located in the left lower quadrant of the abdomen?
a. Liver
b. Duodenum
c. Gallbladder
d. Sigmoid colon
d. Sigmoid colon
RATIONALE: The sigmoid colon is located in the left lower quadrant of the abdomen.
A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:
a. Aphasia.
b. Dysphasia.
c. Dysphagia.
d. Anorexia.
c. dysphagia
RATIONALE: 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.
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
b. Inspect and palpate in the epigastric region
c. Auscultate and percuss in the inguinal region
d. Percuss and palpate the midline area above the suprapubic bone
d. Percuss and palpate the midline area above the suprapubic bone
RATIONALE: Dell percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation
The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:
a. Increased salivation
b. Increased liver size
c. Increased esophageal emptying
d. Decreased gastric acid secretion
d. Decreased gastric acid secretion
RATIONALE: Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed and liver size decreases
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 reports 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.
b. The spleen is normally felt on routine palpation.
c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size.
d. An enlarged spleen should not be palpated because it can easily rupture.
d. An enlarged spleen should not be palpated because it can easily rupture.
RATIONALE: If an enlarged spleen is felt, then the nurse should refer the person and should not continue to palpate it. An enlarged spleen is friable and can easily rupture with overpalpation.
A patients abdomen is bulging and stretched in appearance. The nurse should describe this finding as:
a. Obese.
b. Herniated.
c. Scaphoid.
d. Protuberant.
d. Protuberant.
RAITONALE: A protuberant abdomen is rounded, bulging, and stretched. A scaphoid abdomen caves inward.
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ______ profile.
a. Flat
b. Convex
c. Bulging
d. Concave
d. Concave
RATIONALE: 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.
While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are:
a. Pulsations of the renal arteries.
b. Pulsations of the inferior vena cava.
c. Normal abdominal aortic pulsations.
d. Increased peristalsis from a bowel obstruction.
c. Normal abdominal aortic pulsations.
RATIONALE: Normally, the pulsations from the aorta are observed beneath the skin in the epigastric area, particularly in thin persons who have good muscle wall relaxation.
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
a. Diarrhea.
b. Peritonitis.
c. Laxative use.
d. Gastroenteritis.
b. Peritonitis.
RATIONALE: Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.
The nurse is watching a new graduate nurse perform auscultation of a patients 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.
b. Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.
c. Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination.
d. Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.
b. Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.
RATIONALE: Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds:
a. Are usually loud, high-pitched, rushing, and tinkling sounds.
b. Are usually high-pitched, gurgling, and irregular sounds.
c. Sound like two pieces of leather being rubbed together.
d. Originate from the movement of air and fluid through the large intestine.
b. Are usually high-pitched, gurgling, and irregular sounds.
RATIONALE: 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.
The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:
a. Loud continual hum.
b. Peritoneal friction rub.
c. Hypoactive bowel sounds.
d. Hyperactive bowel sounds.
d. Hyperactive bowel sounds.
RATIONALE: Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.
During an abdominal assessment, the nurse would consider which of these findings as normal?
a. Presence of a bruit in the femoral area
b. Tympanic percussion note in the umbilical region
c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line
d. Dull percussion note in the left upper quadrant at the midclavicular line
b. Tympanic percussion note in the umbilical region
RATIONALE: 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).
The nurse is assessing the abdomen of a pregnant woman who is complaining of having acid indigestion all the time. The nurse knows that esophageal reflux during pregnancy can cause:
a. Diarrhea.
b. Pyrosis.
c. Dysphagia.
d. Constipation.
b. Pyrosis.
RATIONALE: Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct.
The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:
a. Flatness, resonance, and dullness.
b. Resonance, dullness, and tympany.
c. Tympany, hyperresonance, and dullness.
d. Resonance, hyperresonance, and flatness.
c. Tympany, hyperresonance, and dullness.
RATIONALE: 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.
