Questions and Answers
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?
A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
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One change that may occur in the gastrointestinal system of an aging adult is:
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The nurse suspects a patient may have injured his spleen after a fall. Which of these statements is true regarding the assessment of the spleen?
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A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as:
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The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _________ profile.
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While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are:
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A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
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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?
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Which of these statements is true of bowel sounds?
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The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:
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During an abdominal assessment, the nurse would consider which of these findings as normal?
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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:
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The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:
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An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:
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A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of:
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A nurse notices that a patient has ascites, which indicates the presence of:
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The nurse knows that during an abdominal assessment, deep palpation is used to determine:
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The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be:
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During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?
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The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true?
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During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by:
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The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?
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During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least:
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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?
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Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?
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Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?
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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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A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should:
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When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?
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The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group?
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The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem?
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During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to:
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During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition?
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During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:
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The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?
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During a health history, the patient tells the nurse, 'I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!' Based on these symptoms, the nurse suspects that the patient has which condition?
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The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply)
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Study Notes
Abdomen Assessment Key Points
- Percussion over the liver in the right intercostal space leads to dullness, indicating normal liver density.
- The sigmoid colon is located in the left lower quadrant of the abdomen.
- Difficulty in swallowing is documented as dysphagia.
- To assess a suspected distended bladder, palpation and percussion should occur in the midline area above the suprapubic bone.
- Aging may result in decreased gastric acid secretion in the gastrointestinal system.
- Enlarged spleen from trauma should not be palpated due to the risk of rupture.
Abdominal Descriptions
- A bulging abdomen is described as protuberant.
- A scaphoid abdomen has a concave profile.
- Observing abdominal pulsations suggests normal abdominal aortic pulsations.
Bowel Sounds and Conditions
- Hypoactive bowel sounds may indicate peritonitis.
- Auscultation precedes percussion and palpation to prevent distortion of bowel sounds.
- Normal bowel sounds are high-pitched, gurgling, and irregular.
- Borborygmi refers to hyperactive bowel sounds.
Abnormal Findings
- A tympanic percussion note is typically normal in the umbilical region.
- Esophageal reflux during pregnancy often leads to pyrosis (heartburn).
- Ascites indicates fluid accumulation in the abdomen, detectable by dullness during percussion.
- Black, tarry stools can be a sign of gastrointestinal bleeding.
Specific Conditions and Signs
- Tenderness in the right lower quadrant may indicate appendicitis.
- Older adults often have thinner abdominal musculature leading to changes in assessment.
- Pyloric stenosis in infants displays as projectile vomiting.
- A pulsating mass is typically noted in aortic aneurysms, commonly located below the umbilicus.
Clinical Techniques
- To assess cholecystitis, a Murphy sign test is significant.
- A positive fluid wave test is indicative of ascites.
- When assessing right lower quadrant pain, examine tender areas last to avoid discomfort.
Patient History Insights
- Chronic use of nonsteroidal anti-inflammatory drugs is frequently associated with peptic ulcer disease.
- Lactose intolerance is most prevalent among Black adults in the United States.
Other Key Terms
- Hepatomegaly signifies an enlarged liver.
- An umbilical hernia will present as an enlarged and everted umbilicus.
Examination Protocols
- Listen for bowel sounds for 5 minutes before classifying them as silent.
- If the patient reports pain that worsens after eating yet improves with more food, a duodenal ulcer may be suspected.
Assessment Considerations
- Always document findings promptly and refer any significant abnormalities, such as hepatomegaly, to a physician for further evaluation.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge on abdominal anatomy and examination techniques with these flashcards on Chapter 22 by Jarvis. Perfect for nursing students preparing for clinical practice, the quiz covers important structures and sounds associated with abdominal assessment.
