Question 1

A patient is reporting intermittent pain in the left upper abdomen. To best assess the characteristics of the pain, the nurse would ask which questions?. Select all that apply.

Accepted Answer

These questions allow the nurse to assess the location, quality, onset, aggravating and alleviating factors of the patient's pain, which can help in identifying the potential cause and in providing effective pain management. B is not a helpful question to assess the characteristics of the pain because the patient's perception of the cause may not be accurate.

Question 2

It is thought that a patient may be experiencing pancreatitis. Which nursing action would be useful in helping diagnose this disorder?

Accepted Answer

The nursing action of placing the hand on the lateral surface of the patient's flexed right thigh and asking the patient to push against applied resistance is a test called the Cullen's sign. This test can be useful in identifying pancreatitis, as it indicates the presence of intra-abdominal bleeding, which can be a complication of pancreatitis. The other options listed are not useful in diagnosing pancreatitis.

Question 3

When percussing a patient's abdomen to gather assessment data, the nurse must rely most heavily on which ability?

Accepted Answer

Percussion of the abdomen is used to differentiate various sounds that indicate the presence or absence of fluid, gas, or solid tissue. The nurse must rely heavily on the ability to differentiate and interpret these sounds to gather accurate assessment data. While locating the margins of organs and observing contour variations are important, they are not the primary focus of percussion. Fine finger dexterity may be helpful but is not necessary for basic percussion techniques.

Question 4

When assessing a patient who is scheduled to have a CT scan of the kidneys, which finding would prompt the nurse to notify the primary health care provider?

Accepted Answer

An allergy to iodine and seafood may indicate a risk for an adverse reaction to the contrast material used in the CT scan, which contains iodine. The primary healthcare provider should be notified to ensure appropriate measures are taken to prevent a reaction. Urinary output, bowel movements, and height/weight are not significant factors when assessing a patient for a CT scan of the kidneys.

Question 5

Which assessment finding alerts the nurse to the likelihood that the patient has a distended bladder?

Accepted Answer

Percussion in the middle of the lower abdomen elicits a dull sound, which can indicate the presence of a full bladder.

Question 6

Arrange the four parts of abdominal assessment in the order the nurse should follow.
A) Percussion
B) Inspection
C) Palpation
D) Auscultation

Accepted Answer

The answer of Arrange the four parts of abdominal assessment...

Question 7

The nurse evaluates which patient observation as indicating the patient correctly understands the functions of the stomach?

Accepted Answer

The statement "My stomach turns food into liquid so it can be digested" indicates that the patient understands the mechanical digestion function of the stomach, which breaks down food into smaller pieces and mixes it with stomach acid to create a liquid called chyme. The other statements may be partially correct but do not solely address the function of the stomach.

Question 8

The nurse is preparing to assess a patient who reports abdominal pain as 6 on a scale of 0 to

Accepted Answer

Assisting the patient into the knees-bent supine position relaxes the abdominal muscles, facilitating palpation.

Question 9

The nurse is caring for an adolescent who experienced trauma to the spleen that requires its removal. When discussing the proposed surgery with the patient's parents, the nurse would provide which information?. Select all that apply.

Accepted Answer

The spleen is located in the left upper abdominal quadrant, acts as a blood filtration system, and destroys aged red blood cells. Option B is incorrect as the spleen is not involved in the return of bile to the liver. Option C is also incorrect as the spleen has a rich vascular system.

Question 10

Which would the nurse ask to most effectively assess the patient's pattern of elimination?

Accepted Answer

Asking the patient to describe their usual bowel habits will give the nurse the most comprehensive understanding of the patient's pattern of elimination. This question allows the patient to provide information about frequency, consistency, and any potential difficulties they may be experiencing. The other options are more limited in their scope and may not elicit as detailed of a response.

Question 11

A newly licensed nurse is assessing a patient who reports constant dull pain over the lower abdomen. The nurse inspects, percusses, palpates, and auscultates the patient's abdomen. After leaving the patient's room, the preceptor says, "Your assessment findings may not be accurate." What is the rationale for the preceptor's statement?

Accepted Answer

The nurse palpated before auscultating, which can disrupt bowel sounds and give inaccurate assessment findings. The correct order is inspection, auscultation, percussion, and palpation (unless contraindicated).

Question 12

When assessing a patient's abdomen, the nurse recognizes the importance of reserving palpation as the last technique. What rationale would the nurse provide for this sequence?

Accepted Answer

Palpation can stimulate bowel activity, which may alter the frequency and character of bowel sounds, making it difficult to accurately assess them if done before auscultation.

Question 13

The nurse is assessing a 68-year-old female patient who states, "I am having episodes of urinary incontinence." The nurse should recognize that this statement indicates which situation?

Accepted Answer

Urinary incontinence is not a normal outcome of aging or having several children. It can be a symptom of an underlying issue such as a urinary tract infection or pelvic floor dysfunction, and further testing may be necessary to determine the cause.

Question 14

The nurse is teaching a patient who has a diagnosis of a kidney stone in the left ureter. The nurse knows the patient understands the instruction when the patient makes which statement?

Accepted Answer

This statement demonstrates understanding that the kidney stone is currently in the ureter and may potentially move into the bladder as it continues to travel downward. Options A and B are incorrect as they do not accurately describe the location or source of the patient's pain. Option D is incorrect as the kidney does not contract to push the stone down the ureter - this occurs through peristalsis of the ureter.

Question 15

The nurse is percussing a patient's kidneys as part of the physical assessment. Which nursing action displays a need for further instruction regarding this assessment technique?

Accepted Answer

Percussing a patient's kidneys should involve using the ulnar edge of one hand as a hammer, striking the dorsum of the other hand positioned over the patient's costovertebral angle. Using the palmar surface of the hand is incorrect technique.

Question 16

A nurse preceptor is reviewing the skill of percussing a patient's abdomen with a newly licensed nurse. The preceptor will intervene when the nurse makes which statement?

Accepted Answer

Anticipating hearing tympany over stool-filled intestines is incorrect. Tympany is the expected percussion over air-filled intestines, while dullness is expected over stool-filled intestines.

Question 17

The patient reports feeling pain in the right lower quadrant. The nurse shows an understanding of the anatomical location of organs in the abdomen by asking the patient which question?

Accepted Answer

Pain in the right lower quadrant could be indicative of issues with the appendix or colon, so asking about bowel habits can help to narrow down potential causes. The other answer choices are not as relevant to the specific location of the reported pain.

Question 18

The nurse is initiating a history and physical assessment on a patient who reports intermittent right-sided abdomen pain, especially after eating fatty foods. How should the nurse conduct the history?. Select all that apply.

Accepted Answer

The nurse should establish a rapport and trust with the patient by encouraging them to express their concerns and using open-ended questions to gather information, including documentation of the patient's own words. Direct questioning should be avoided as it may make the interview feel like an interrogation. While the patient's symptoms may suggest a gallbladder problem, the nurse should gather a more comprehensive history to rule out other potential causes.

Question 19

An older adult patient states, "My mouth is always dry." The nurse recognizes that which priority health promotion problem should be addressed?

Accepted Answer

A dry mouth lacks the necessary saliva to provide a protective barrier against bacteria. Saliva contains immunoglobulin A, which plays a crucial role in fighting off bacteria and maintaining oral health. Without adequate saliva production, the mouth becomes more susceptible to infections and dental problems.

Question 20

During an assessment of a patient's abdomen, frequent pulsations are noted in the epigastric region. What action by the nurse is indicated?

Accepted Answer

Frequent pulsations in the epigastric region can be a sign of an abdominal aortic aneurysm or renal artery stenosis. Therefore, auscultation for a bruit should be performed to determine if there is an underlying vascular abnormality. Documenting the findings as hyperactive bowel sounds or reviewing the patient's medical records for signs of ascites may not be relevant to the pulsations seen. Noting the time the patient last voided may be important for other abdominal assessments, but it is not specific to this finding.

Quiz 36: Nursing Assessment of the Patient With Gastrointestinal, Renal, or Urinary Disorders