Question 1

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?

Accepted Answer

Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.

Question 2

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?

Accepted Answer

The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

Question 3

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?

Accepted Answer

The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

Question 4

During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this?

Accepted Answer

Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.

Question 5

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true?

Accepted Answer

In the older adult, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with an acute abdominal condition is less common in the aging person. The older adult with an acute abdominal condition often complains less about pain than the younger person.

Question 6

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?

Accepted Answer

The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall. The nurse should acknowledge the patient's concerns and not tell him not to worry about it or refer him to his physician to explain it. It is not a result of prenatal growth abnormalities.

Question 7

Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?

Accepted Answer

At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton's jelly. The umbilical stump dries within a week, hardens, and falls off in 10 to 14 days. Skin will cover the area in 3 to 4 weeks.

Question 8

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?

Accepted Answer

The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant. The spleen is in the left upper quadrant; the sigmoid is in the left lower quadrant; and the gallbladder is in the right upper quadrant.

Question 9

The nurse is reviewing information on lactose intolerance and learned that in some racial groups lactase activity (ability to digest and absorb lactose) is high at birth but declines to low levels by adulthood. Which ethnic group has the highest potential for lactose-intolerance symptoms in adulthood?

Accepted Answer

Millions of American adults have the potential for lactose-intolerance symptoms; while 70-80% of White Americans produce lactase adequately into adulthood, only 30% of Mexican Americans, 20% of African Americans, and no American Indians will maintain adequate ability to digest lactose without adverse symptoms.

Question 10

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?

Accepted Answer

The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.

Question 11

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?

Accepted Answer

A large amount of ascitic fluid produces a dull sound to percussion. Flatness is not a term used to describe a percussed sound. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as with gaseous distention of the intestines in the abdomen, not with ascites or fluid. Tympany normally is the predominant sound heard on abdominal auscultation, but it is not heard with ascites, or fluid, in the abdomen.

Question 12

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.)

Accepted Answer

Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites.

Question 13

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. How should the nurse proceed?

Accepted Answer

A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.

Question 14

During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?

Accepted Answer

If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.

Question 15

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?

Accepted Answer

Normally palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy test). The person feels sharp pain and abruptly stops midway during inspiration. The obturator and iliopsoas muscle tests assess for an inflamed appendix. Although a patient with cholecystitis may have rebound tenderness, the presence of rebound tenderness indicates peritoneal inflammation which could be caused by several things so it is not specific to cholecystitis.

Question 16

The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this disorder?

Accepted Answer

Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the stomach or small intestine. The acid can create a painful open sore that may bleed. Peptic ulcers often occur with the frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infections all of which can cause inflammation and irritation to the stomach lining or mucosa.

Question 17

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?

Accepted Answer

Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may be relieved by eating more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.

Question 18

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?

Accepted Answer

Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent.

Question 19

During the change-of-shift report, the student nurse hears that a patient has hepatomegaly. What should the student recognizes that this term means?

Accepted Answer

The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

Quiz 22: Abdomen