Chapter 23: Assessing Abdomen

Question 1

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

a. rectal abdominis
b. transverse abdominis
c. abdominal oblique
d. umbilical oblique

Answer 1

c. abdominal oblique

Question 2

The sigmoid colon is located in this area of the abdomen: the

a. left upper quadrant
b. left lower quadrant
c. right upper quadrant
d. right lower quadrant

Answer 2

b. left lower quadrant

Question 3

The pancreas of an adult client is located

a. below the diaphragm and extending below the right costal margin
b. posterior to the left midaxillary line and posterior to the stomach
c. high and deep under the diaphragm and can be palpated
d. deep in the upper abdomen and is not normally palpable

Answer 3

d. deep in the upper abdomen and is not normally palpable

Question 4

The primary function of the gallbladder is to

a. store and excrete bile
b. aid in the digestion of protein
c. produce alkaline mucus
d. produce hormones

Answer 4

a. store and excrete bile

Question 5

The colon originates in this abdominal area: the

a. right lower quadrant
b. right upper quadrant
c. left lower quadrant
d. left upper quadrant

Answer 5

a. right lower quadrant

Question 6

Inspiratory arrest or causes client to hold breath

Answer 6

Murphy sign

Question 7

Right upper quadrant (RUQ) pain or tenderness

Answer 7

Cholecystitis

Question 8

Bacterium Helicobacter pylori

Answer 8

Peptic ulcer disease

Question 9

Shifting dullness and fluid wave tests

Answer 9

Ascites

Question 10

Can identify a mass or enlarged organ in an ascitic abdomen

Answer 10

Ballottement test

Question 11

Absent or high-pitched bowel sounds

Answer 11

Paralytic ileus

Question 12

Assessed by raising right leg from hip

Answer 12

Positive psoas sign

Question 13

Release of pressure quickly after deep palpation

Answer 13

Rebound tenderness

Question 14

Protrusion of the bowel through the abdominal wall

Answer 14

Hernia

Question 15

Increased peristaltic waves

Answer 15

Intestinal obstruction

Question 16

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client’s

a. right upper quadrant
b. right lower quadrant
c. left upper quadrant
d. left lower quadrant

Answer 16

a. right upper quadrant

Question 17

To palpate for tenderness of an adult client’s appendix, the nurse should begin the abdominal assessment at the client’s

a. left upper quadrant
b. left lower quadrant
c. right upper quadrant
d. right lower quadrant

Answer 17

d. right lower quadrant

Question 18

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment at the client at the

a. left lower quadrant
b. left upper quadrant
c. right upper quadrant
d. right lower quadrant

Answer 18

b. left upper quadrant

Question 19

The nurse plans to assess an adult client’s kidneys for tenderness. The nurse should assess the area at the

a. right upper quadrant
b. left upper quadrant
c. external oblique angle
d. costovertebral angle

Answer 19

d. costovertebral angle

Question 20

The client visits the clinic because she experienced bright hematemesis yesterday. the nurse should refer the client to a physician because this symptom is indicative of

a. stomach ulcers
b. pancreatic cancer
c. decreased gastric motility
d. abdominal tumors

Answer 20

a. stomach ulcers

Question 21

The nurse is assessing an older adult client who has lost 2.27 kg (5 lb) since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. the nurse should further assess the client for

a. peptic ulcer
b. bulimia
c. appetite changes
d. pancreatic disorders

Answer 21

c. appetite changes

Question 22

A client visits the clinic visits there 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

a. “I can decrease the constipation if I eat foods high in fiber and drink water”
b. “I should cut down on the number of iron tablets I am taking each day”
c. “constipation should decrease if I take the iron tablets with milk”
d. “I should discontinue the iron tablets and eat foods that are high in iron”

Answer 22

a. “I can decrease the constipation if I eat foods high in fiber and drink water”

Question 23

The nurse is caring for a female client during her first postoperative day after a temporary colostomy. The client refuses to look at the colostomy bag or the area. A priority nursing diagnosis for this client is

a. denial related to temporary colostomy
b. fear related to potential outcome of surgery
c. disturbed body image related to temporary colostomy
d. altered role functioning related to frequent colostomy bag changes

Answer 23

c. disturbed body image related to temporary colostomy

Question 24

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first

a. palpate the incision site
b. auscultate for bowel sounds
c. percuss for tympany
d. inspect the abdominal area

Answer 24

d. inspect the abdominal area

Question 25

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should

a. ask the client to empty his bladder
b. place the client in a side-laying position
c. ask the client to hold his breath for a few seconds
d. tell the client to raise his arms above his head

Answer 25

a. ask the client to empty his bladder

Question 26

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible

a. liver disease
b. abdominal distention
c. Cushing syndrome
d. internal bleeding

Answer 26

d. internal bleeding

Question 27

While assessing an adult client’s abdomen, the nurse observes that the client’s umbilicus is deviated tot he left. The nurse should refer the client to a physician for possible

a. gallbladder disease
b. cachexia
c. kidney trauma
d. masses

Answer 27

d. masses

Question 28

While assessing an adult client’s abdomen, the nurse observes that the client’s umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible

a. umbilical hernia
b. ascites
c. intra-abdominal bleeding
d. pancreatitis

Answer 28

a. umbilical hernia

Question 29

The nurse assess an adult male client’s abdomen and observes diminished abdominal respirations. The nurse determines that the client should be further assessed for

a. liver disease
b. umbilical hernia
c. intestinal obstruction
d. peritoneal irritation

Answer 29

d. peritoneal irritation

Question 30

The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible

a. aortic aneurysm
b. paralytic ileus
c. gastroenteritis
d. fluid and electrolyte imbalance

Answer 30

b. paralytic ileus

Question 31

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

a. intestinal obstruction
b. gastroenteritis
c. inflamed appendix
d. cirrhosis of the liver

Answer 31

a. intestinal obstruction

Question 32

During a physical examination of an adult client, the nurse is preparing to auscultate the client’s abdomen. The nurse should

a. palpate the abdomen
b. listen in each quadrant for 15 seconds
c. use the diaphragm of the stethoscope
d. begin auscultation in the left upper quadrant

Answer 32

c. use the diaphragm of the stethoscope

Question 33

To palpate the spleen of an adult client, the nurse should

a. ask the client to exhale deeply
b. place the right hand below the left costal margin
c. point the fingers of the left hand downward
d. ask the client to remain in a supine position

Answer 33

b. place the right hand below the left costal margin

Question 34

The nurse is planning to assess a client’s abdomen for rebound tenderness. The nurse should

a. perform this abdominal assessment first
b. ask the client to assume a side-lying position
c. palpate lightly while slowly releasing pressure
d. palpate deeply while quickly releasing pressure

Answer 34

d. palpate deeply while quickly releasing pressure

Question 35

To assess an adult client for possible appendicitis and a positive posts sign, the nurse should

a. rotate the client’s knee internally
b. palpate at the lower right quadrant
c. raise the client’s right leg from the hip
d. support the client’s right knee and ankle

Answer 35

c. raise the client’s right leg from the hip