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Questions and Answers
During the abdominal assessment, how should the nurse proceed if she notices an area of dullness above the right costal margin of approximately 11 cm?
During the abdominal assessment, how should the nurse proceed if she notices an area of dullness above the right costal margin of approximately 11 cm?
- Document the presence of hepatomegaly.
- Ask additional health history questions regarding his alcohol intake.
- Describe this dullness as indicative of an enlarged liver, and refer him to a physician.
- Consider this finding as normal, and proceed with the examination. (correct)
Which structure is most likely to be involved if a nurse notices tenderness in the left upper quadrant during palpation of a 20-year-old patient's abdomen?
Which structure is most likely to be involved if a nurse notices tenderness in the left upper quadrant during palpation of a 20-year-old patient's abdomen?
- Spleen (correct)
- Appendix
- Sigmoid colon
- Gallbladder
Which ethnic group has the highest potential for lactose intolerance symptoms in adulthood?
Which ethnic group has the highest potential for lactose intolerance symptoms in adulthood?
- White Americans
- African Americans
- Asians
- American Indians (correct)
Which condition or history often causes peptic ulcer disease?
Which condition or history often causes peptic ulcer disease?
What does the term hepatomegaly mean?
What does the term hepatomegaly mean?
What condition may be indicated by an enlarged and everted umbilicus positioned midline with no change in skin color?
What condition may be indicated by an enlarged and everted umbilicus positioned midline with no change in skin color?
What condition would produce a positive fluid wave test during an abdominal assessment?
What condition would produce a positive fluid wave test during an abdominal assessment?
Which technique is correct during the assessment of a patient complaining of right lower quadrant pain?
Which technique is correct during the assessment of a patient complaining of right lower quadrant pain?
Based on the symptoms of pain worsening 2 hours after eating but improving with food, what condition does the nurse suspect?
Based on the symptoms of pain worsening 2 hours after eating but improving with food, what condition does the nurse suspect?
Which procedures are appropriate when assessing for appendicitis or a perforated appendix? (Select all that apply)
Which procedures are appropriate when assessing for appendicitis or a perforated appendix? (Select all that apply)
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
Which structure is located in the left lower quadrant of the abdomen?
Which structure is located in the left lower quadrant of the abdomen?
A patient is having difficulty swallowing medications and food. How should the nurse document this?
A patient is having difficulty swallowing medications and food. How should the nurse document this?
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
The nurse is aware that what change may occur in the gastrointestinal system with aging?
The nurse is aware that what change may occur in the gastrointestinal system with aging?
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 handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding the assessment of the spleen in this situation?
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 handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding the assessment of the spleen in this situation?
A patient's abdomen is bulging and stretched in appearance. How should the nurse document this finding?
A patient's abdomen is bulging and stretched in appearance. How should the nurse document this finding?
The nurse is describing a scaphoid abdomen. When assessing the contour of the abdomen from the rib margin to the pubic bone, what would the contour look like?
The nurse is describing a scaphoid abdomen. When assessing the contour of the abdomen from the rib margin to the pubic bone, what would the contour look like?
While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and the umbilicus. What does the nurse suspect?
While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and the umbilicus. What does the nurse suspect?
A patient has hypoactive bowel sounds. What is a possible cause of this finding?
A patient has hypoactive bowel sounds. What is a possible cause of this finding?
The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?
The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?
The physician comments that a patient has abdominal borborygmi. What is the best description of this term?
The physician comments that a patient has abdominal borborygmi. What is the best description of this term?
During an abdominal assessment, the nurse would consider which of these findings as normal?
During an abdominal assessment, the nurse would consider which of these findings as normal?
The nurse is assessing the abdomen of a pregnant woman who states she has been having 'acid indigestion' all the time. What does the nurse know that esophageal reflux during pregnancy can cause?
The nurse is assessing the abdomen of a pregnant woman who states she has been having 'acid indigestion' all the time. What does the nurse know that esophageal reflux during pregnancy can cause?
The nurse is performing an abdominal assessment. What types of percussion notes can be heard during abdominal assessment?
The nurse is performing an abdominal assessment. What types of percussion notes can be heard during abdominal assessment?
An older patient has been diagnosed with pernicious anemia. This disorder could be related to what condition?
An older patient has been diagnosed with pernicious anemia. This disorder could be related to what condition?
A patient is reporting sharp pain along the costovertebral angles. What does this symptom most often indicate?
A patient is reporting sharp pain along the costovertebral angles. What does this symptom most often indicate?
A nurse notices that a patient has abdominal ascites. What does this finding indicate?
A nurse notices that a patient has abdominal ascites. What does this finding indicate?
The nurse notices that a patient has had a black, tarry stool. What should the nurse recognize may cause this finding?
The nurse notices that a patient has had a black, tarry stool. What should the nurse recognize may cause this finding?
During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure?
During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure?
The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true?
The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true?
During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this?
During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this?
The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?
The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?
A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?
A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?
Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?
Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?
Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?
Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?
A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?
A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?
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Study Notes
Abdominal Assessment Insights
- Percussion Sounds: Dullness is expected over the liver during percussion; tympany predominates in air-filled organs, while resonance implies healthy lung tissue.
- Organ Location: Sigmoid colon is found in the left lower quadrant, while the liver and gallbladder are both in the right upper quadrant.
Clinical Terminology
- Dysphagia refers to difficulty swallowing; differentiates from anorexia (loss of appetite) and aphasia/dysphasia (speech disorders).
- Ascites indicates an abnormal fluid accumulation in the peritoneal cavity, often associated with conditions like liver disease or cancer.
Abdominal Changes in Aging
- Gastrointestinal Changes: Decreased gastric acid secretion occurs with aging, which affects digestion and nutrient absorption, potentially leading to conditions such as pernicious anemia.
Abdominal Assessment Techniques
- Listen for absent bowel sounds for at least 5 minutes before concluding absence, as this might indicate reduced gastrointestinal motility.
- Murphy's sign tests for gallbladder inflammation; pain upon palpation during deep inspiration suggests cholecystitis.
Specific Signs and Symptoms
- Pyloric Stenosis: In newborns, projectile vomiting and noticeable peristalsis can indicate this condition.
- Abdominal pain in the costovertebral angle often signals kidney inflammation.
Hernia and Aneurism Basics
- A hernia is defined as a loop of bowel protruding through an opening in the abdominal wall.
- A pulsating mass upon examination is an indicator of an aortic aneurysm.
Normal and Abnormal Findings
- Borborygmi: Loud gurgling bowel sounds indicating hyperperistalsis.
- Ascitic Fluid: Causes dullness on percussion in the abdomen, as air typically generates a tympanic sound.
Nutritional Considerations
- Lactose intolerance varies by ethnicity; American Indians show the highest prevalence due to reduced lactase production in adulthood.
Key Points on Patient Symptoms
- Black, tarry stool (melena) may signify gastrointestinal bleeding, while hypoactive bowel sounds could suggest inflammation like peritonitis.
- Abdominal rigidity is less common in older adults experiencing acute abdominal conditions compared to younger individuals.
General Survey of Abdominal Assessment
- Inspect, palpate, and auscultate systematically; auscultation is prioritized to avoid altering bowel sounds with percussion and palpation.
- The spleen is normally not palpable; an enlarged spleen, due to trauma or disease, can indicate serious health issues.### Peptic Ulcers
- Peptic ulcers are open sores in the stomach or small intestine caused by digestive acids.
- Frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs) significantly increases the risk for developing peptic ulcers.
- Other contributing factors include alcohol consumption, smoking, and infections from Helicobacter pylori, which lead to stomach lining inflammation.
Hepatomegaly
- Hepatomegaly is defined as an enlarged liver.
- It is essential to differentiate hepatomegaly from other conditions, such as splenomegaly (enlarged spleen).
Umbilical Hernia
- An enlarged and everted umbilicus that is midline with no skin discoloration may indicate an umbilical hernia.
- Normal umbilicus positioning is usually midline and inverted without any signs of swelling.
Ascites
- A positive fluid wave test indicates the presence of ascites, which is fluid accumulation in the abdomen.
- Other conditions like splenomegaly, constipation, or a distended bladder would not yield a positive fluid wave.
Abdominal Assessment Technique
- During abdominal assessments, tender areas should be examined last to avoid exacerbating pain and muscle rigidity.
- Auscultation is performed before percussion and palpation to prevent misinterpretation of bowel sounds.
Duodenal Ulcers
- Pain 2 to 3 hours after eating and relief upon further eating suggests a duodenal ulcer.
- In contrast, gastric ulcer pain typically occurs on an empty stomach.
Appendicitis Assessment
- Examining rebound tenderness (Blumberg sign) and performing the iliopsoas muscle test are crucial when assessing for appendicitis or potential perforation.
- The Murphy sign is related to gallbladder inflammation, not appendicitis, while fluid wave and shifting dullness tests are for assessing ascites.
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