Deck 20: Abdomen

Question 1

The nurse documents "pain noted during palpation at McBurney's point." Which describes the techniques used during the assessment?

A) The nurse lightly palpated the around the client's umbilicus.
B) The nurse pressed into the client's abdomen and then pulled his hand back quickly.
C) The nurse palpated over the client's spleen.
D) The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.

Answer 1

The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.

Question 2

The nurse is palpating the left upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply.

A) Liver.
B) Gallbladder.
C) Appendix.
D) Spleen.
E) Stomach.

Answer 2

Spleen.
Stomach.

Question 3

A client asks the nurse, "What's the purpose of a gallbladder anyway? My mom lived for many years without her gallbladder." Which information would be beneficial for the nurse to share with this client?

A) "You are right. We still don't know the function of the gallbladder."
B) "It stores bile until it is needed for digestion of fats."
C) "It destroys old red blood cells."
D) "It helps you digest carbohydrates by producing enzymes."

Answer 3

"It stores bile until it is needed for digestion of fats."

Question 4

The nurse is performing reviewing the risk factors for colorectal cancer with a client. Which information should the nurse include? Select all that apply.

A) Stress.
B) Smoking.
C) Diabetes.
D) Obesity.
E) Diet high in red meat.

Question 5

The nurse is preparing to examine a client who is complaining of right lower quadrant abdominal pain. Which actions by the nurse are appropriate in this situation? Select all that apply.

A) "It is a little cool in our examination room; may I turn up the thermostat?"
B) "I've been told you are experiencing some pain in the lower right area of your abdomen. I will examine that area first."
C) "I am going to stand on your left side so I can feel your liver better."
D) "I'm going to place this drape over you so you don't feel too exposed during this examination."
E) "I am going to place this pillow behind your head and this pillow under your knees."

Question 6

A client asks the nurse where their spleen is located. Which response should the nurse provide?

A) "Just above the umbilicus."
B) "Upper midline area of your abdomen."
C) "Right upper side of your abdomen."
D) "Left upper side of your abdomen."

Question 7

The nurse is assessing a client in the emergency department (ED)who complains of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. Based on the client's assessment data, which conditions does the nurse suspect? Select all that apply.

A) Constipation.
B) Appendicitis.
C) Cholecystitis.
D) Small bowel obstruction.
E) Peritonitis.

Question 8

The nurse is completing discharge instructions for a client admitted with esophagitis. Which client statements indicate the need for further education? Select all that apply.

A) "I'm going to talk to my doctor about a nicotine patch."
B) "I can do all of this stuff you're talking about as long as I don't have to give up my beer."
C) "I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle."
D) "The root of this problem is that I just sleep too much."
E) "I told my wife to stop making serving me all of those vegetables."

Question 9

The nurse is performing an abdominal assessment on a client. While the nurse is palpating the lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client complains of a sharp pain located in the right upper quadrant. How will the nurse document this finding in the medical record?

A) Positive Blumberg's sign.
B) Presence of pain at McBurney's point.
C) Positive Murphy sign.
D) Positive psoas sign.

Question 10

A client asks the nurse where their appendix is. Which response should the nurse provide?

A) "It is attached to the large intestine."
B) "It is attached to the sigmoid colon."
C) "It is attached to the large intestine at the cecum."
D) "It is attached to the small intestine at the cecum."

Question 11

The client states, "No one will let me eat or drink anything until after my test and it's been 9 hours since I last ate anything." While auscultating the client's abdomen, the nurse hears frequent bowel sounds. How will the nurse document this finding in the medical record?

A) Borborygmi present.
B) Hypoactive bowel sounds present.
C) Bruit present.
D) Friction rub present.

Question 12

A client asks the nurse, "What's the purpose of the liver?" Which statements will the nurse include in the response to this client's question? Select all that apply.

A) "It helps you digest fats."
B) "It is an endocrine and exocrine gland."
C) "It filters waste from the blood and makes urine."
D) "It makes some blood-clotting substances."
E) "It can help you store certain vitamins."

Question 13

The nurse is palpating the right upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply.

A) Liver.
B) Gallbladder.
C) Appendix.
D) Spleen.
E) Stomach.

Question 14

The nurse is preparing to assess the abdomen of a client suspected of having an appendicitis. Which should the nurse include in the plan for the abdominal assessment?

A) Avoid palpation.
B) Palpate the area last.
C) Percuss the area first.
D) Auscultate the area first.

Question 15

The nurse is performing an abdominal assessment on a client. During the focused interview, the client tells the nurse about recently experiencing abdominal pain. As the nurse assesses the client, which behaviors indicate that the client may be experiencing pain or anxiety during the examination? Select all that apply.

A) The client is diaphoretic.
B) The client moves away from the nurse's hands.
C) The client grimaces.
D) The client pulls his knees toward his stomach.
E) The client coughs loudly.

Question 16

The nurse is mapping the client's abdomen into four quadrants. Which landmarks would the nurse use to perform this assessment? Select all that apply.

A) Umbilicus.
B) Midclavicular lines.
C) Xiphoid process.
D) Lower border of the right ribs.
E) Iliac crests.

Question 17

The client was recently admitted to the hospital with left lower quadrant pain. The client states, "It feels like my belly is cramping." During the focused interview, the client admitted to experiencing a significant amount of occupational stress. Guarding is noted during the abdominal examination. The nurse reviews the medical record (see chart below)and concludes that the client has developed a diverticulitis. Which client statement supports this conclusion by the nurse?

A) "I get home so late at night, but I've got to stop lying down right after dinner."
B) "I drink a whole pot of coffee every day."
C) "I drink 9-12 beers after I get home from work, every day."
D) "We have been growing green beans in our garden and I think I ate too many the other day."

Question 18

The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back. The client states, "This has been happening more often after I eat rich, high-fat foods." Which question should the nurse include in the history?

A) "Do you have a history of cholecystitis?"
B) "Do you have a history of a duodenal ulcer?"
C) "Do you have a history of gastritis?"
D) "Do you have a history of pancreatitis?"

Question 19

The nurse is assessing the client's abdomen and notes dullness when percussing over the left lower quadrant. Which question is most appropriate for the nurse to ask the client at this time?

A) "How much alcohol do you drink?"
B) "Do you have pain after eating?"
C) "When was your last bowel movement?"
D) "Have you ever had splenomegaly?"

Question 20

The nurse is preparing to percuss over the left upper portion of the client's abdomen. The client states, "I haven't had my breakfast, yet." Based on this statement, which does the nurse anticipate?

A) Dullness.
B) Flatness.
C) Tympany.
D) Hyperresonance.

Question 21

The nurse is preparing to assess a client newly diagnosed with stomach cancer. Which assessment findings should the nurse anticipate? Select all that apply.

A) Diarrhea.
B) Vomiting.
C) Gastrointestinal bleeding.
D) Abdominal distention.
E) Dark-colored urine.

Question 22

A client tells the nurse they are frequently under a great deal of stress. Which common gastrointestinal disorder should the nurse recognize the client is at risk for? Select all that apply.

A) Diverticulitis.
B) Duodenal ulcer.
C) Gastritis.
D) Gastroesophageal Reflux Disorder.
E) Irritable bowel syndrome.

Question 23

The nurse is performing an abdominal assessment on an infant. The nurse notes that the umbilicus is bulging and has been displaced slightly to the left of midline. Based on this data, which diagnosis does the nurse anticipate?

A) Infection.
B) Umbilical hernia.
C) Ventral hernia.
D) Hiatal hernia.

Question 24

The nurse is caring for a client diagnosed with the hepatitis A virus. The client requests information about how the virus is transmitted. Which statement by the nurse is appropriate?

A) "This virus is transmitted by sexual contact with someone who already has been infected with this virus."
B) "Most likely, you ate something that was contaminated with the virus."
C) "It is spread by blood transfusions."
D) "Have you ever injected an illegal drug?"

Question 25

The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. The nurse inspected the client's abdomen and notes ascites. Based on this data, which interventions will the nurse perform next? Select all that apply.

A) Obtain stool specimen for occult blood.
B) Measure the client's abdominal girth.
C) Obtain stool specimen for culture and sensitivity.
D) Bilateral leg measurements.
E) Percuss the abdomen at midline.

Question 26

The nurse is interviewing an older adult Hispanic client who complains of recent weight loss, anorexia, and epigastric pain. The client reports recent use of "mints" for stomach upset. Based on this assessment data, which interventions are appropriate for this client? Select all that apply.

A) Schedule the client for an endoscopy as ordered.
B) Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider.
C) Educate the client regarding Helicobacter pylori infections.
D) Discuss the importance of using over-the-counter aspirin for mild pain relief.
E) Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer.

Question 27

The nurse is auscultating the abdomen of a client for vascular sounds. The nurse hears a soft, continuous humming sound. Based on this data, the nurse suspects dysfunction with which organ?

A) Stomach.
B) Spleen.
C) Pancreas.
D) Liver.

Question 28

The nurse has discussed the precipitating factors of pancreatitis with a client. Which statement made by the client indicates an understanding of the information?

A) "I will cut back on my drinking."
B) "I will no longer use acetaminophen."
C) "I am working with a dietician to reduce my weight."
D) "I am working to get my diabetes under control."

Question 29

The pediatric nurse is preparing an educational presentation for parents of school-aged children regarding hepatitis. Based on the pediatric risk, which type of hepatitis virus will the nurse focus on during the educational session?

A) Hepatitis A virus.
B) Hepatitis B virus.
C) Hepatitis C virus.
D) Hepatitis D virus.

Question 30

The nurse is performing an abdominal assessment on the client. Rank the assessment steps in the order in which they should occur.

A) Percuss the abdomen.
B) Visualize the quadrants of the abdomen.
C) Palpate the abdomen.
D) Auscultate the abdomen.
E) Encourage the client to void.