Chapter 23: Assessing Abdomen Flashcards
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
c. abdominal oblique
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
b. left lower quadrant
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
d. deep in the upper abdomen and is not normally palpable
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
a. store and excrete bile
The colon originates in this abdominal area: the
a. right lower quadrant
b. right upper quadrant
c. left lower quadrant
d. left upper quadrant
a. right lower quadrant
Inspiratory arrest or causes client to hold breath
Murphy sign
Right upper quadrant (RUQ) pain or tenderness
Cholecystitis
Bacterium Helicobacter pylori
Peptic ulcer disease
Shifting dullness and fluid wave tests
Ascites
Can identify a mass or enlarged organ in an ascitic abdomen
Ballottement test
Absent or high-pitched bowel sounds
Paralytic ileus
Assessed by raising right leg from hip
Positive psoas sign
Release of pressure quickly after deep palpation
Rebound tenderness
Protrusion of the bowel through the abdominal wall
Hernia
Increased peristaltic waves
Intestinal obstruction
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
a. right upper quadrant
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
d. right lower quadrant
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
b. left upper quadrant
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
d. costovertebral angle
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
a. stomach ulcers
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
c. appetite changes
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”
a. “I can decrease the constipation if I eat foods high in fiber and drink water”
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
c. disturbed body image related to temporary colostomy
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
d. inspect the abdominal area
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
a. ask the client to empty his bladder
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
d. internal bleeding
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
d. masses
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
a. umbilical hernia
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
d. peritoneal irritation
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
b. paralytic ileus
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
a. intestinal obstruction
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
c. use the diaphragm of the stethoscope
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
b. place the right hand below the left costal margin
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
d. palpate deeply while quickly releasing pressure
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
c. raise the client’s right leg from the hip
