Questions and Answers
A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ?
A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment?
A 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 nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following?
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A nurse receives an order to measure the abdominal girth daily on a client admitted with ascites. How should the nurse best implement this order?
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A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process?
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Study Notes
Abdominal Assessment
- Costovertebral angle tenderness indicates kidney issues such as pyelonephritis or renal calculi.
- Liver tenderness is assessed via percussion technique with specific positioning.
- Spleen tenderness is evaluated by percussion that changes tone; gallbladder tenderness is not percussed.
Client Comfort During Assessment
- Placing a small pillow under the client's knees helps relax abdominal muscles during assessment.
- Avoid raising the head of the bed or having the client sit with legs dangling, as these can increase tension.
Hematemesis Implications
- Bright hematemesis, or vomiting blood, is often associated with stomach ulcers, necessitating referral to a physician.
- Other conditions like pancreatic cancer and abdominal tumors may present similarly but require separate considerations.
Anatomy of the Abdomen
- The linea alba is a white vertical line formed by the joining of muscle fibers at the midline, extending from the xiphoid process to the symphysis pubis.
- The abdominal wall consists of three layers of muscle: external abdominal oblique, internal abdominal oblique, and transverse abdominis.
- The peritoneum lines the abdominal cavity and covers internal organs.
Measuring Abdominal Girth
- Daily measurements of abdominal girth should be taken at the same time, preferably morning after voiding, using the umbilicus as a reference.
- The optimal measurement position is standing; if unable, a supine position is recommended with the head of the bed flat.
Diagnosis Based on Symptoms
- A transverse scar in the right lower quadrant suggests potential internal adhesions from previous surgery, possibly causing pulling sensations.
- It's essential to differentiate between pain types; intestinal obstructions typically do not present with a pulling feeling but with nausea and vomiting along with pain.
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Description
Test your knowledge on abdominal assessment with this quiz focused on the costovertebral angle and its implications. The quiz features scenarios and questions related to detecting abnormalities in organs like the kidney, liver, and more.
