Chapter 21

The nurse is preparing to perform an abdominal assessment. The client states, “Can you point to where my appendix is located?” Which location will the nurse point to when answering this client’s question?. A. B. C. D.

The nurse is speaking with the client during the focused interview. The client states, “My doctor said that my spleen was enlarged. Where is my spleen?” Which location will the nurse point to when answering this client’s question?. A. B. C. D.

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? Standard Text: Select all that apply. “It helps you digest fats.”. “It is an endocrine and exocrine gland.”. “It filters waste from the blood and makes urine.”. “It makes some blood-clotting substances.”. “It can help you store certain vitamins.”.

The nurse is palpating the right upper quadrant of a client’s abdomen. Which organs may be assessed during this portion of the assessment? Standard Text: Select all that apply. Liver. Gallbladder. Appendix. Spleen. Stomach.

A client asks the nurse, “What’s the purpose of a gall bladder anyway? My mom lived for many years without her gallbladder.” Which information would be beneficial for the nurse to share with this client?. “You are right. We still don’t know the function of the gallbladder.”. “It stores bile until it is needed for digestion of fats.”. “It destroys old red blood cells.”. “It helps you digest carbohydrates by producing enzymes.”.

The nurse is palpating the left upper quadrant of a client’s abdomen. Which organs may be assessed during this portion of the assessment? Standard Text: Select all that apply. Liver. Gallbladder. Appendix. Spleen. Stomach.

The nurse is mapping the client’s abdomen into four quadrants. Which landmarks would the nurse use to perform this assessment? Standard Text: Select all that apply. Umbilicus. Midclavicular lines. Xiphoid process. Lower border of the right ribs. Iliac crests.

The nurse is performing a focused interview with an older adult client. Which statements by the client are expected? Standard Text: Select all that apply. “I have been having loose stools every day for the last 3 years.”. “I know I just don’t drink as much water as I should.”. “My belly seems softer and flabbier as I get older.”. “My mouth is always dry.”. “My heartburn gets worse the older I get.”.

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? Standard Text: Select all that apply. “It is a little cool in our examination room; may I turn up the thermostat?”. “I’ve been told you are experiencing some pain in the lower right area of your abdomen. I will examine that area first.”. “I am going to stand on your left side so I can feel your liver better.”. “I’m going to place this drape over you so you don’t feel too exposed during this examination.”. “I am going to place this pillow behind your head and this pillow under your knees.”.

The nurse is performing an abdominal assessment on a client. During the focused interview, the client tells the nurse about experiencing some abdominal pain recently. As the nurse assesses the client, which behaviors indicate that the client may be experiencing pain or anxiety during the examination? Standard Text: Select all that apply. The client’s respiratory rate is 26 per minute. The client moves away from the nurse’s hands. The client grimaces. The client pulls his knees toward his stomach. The client coughs loudly.

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? Assessment or diagnostic test Results White blood cell count 25,000/mm3 Red blood cell count 4.2 x 1012/L Temperature 101.2 degrees Fahrenheit Blood pressure 152/84. “I get home so late at night, but I’ve got to stop lying down right after dinner.”. “I drink a whole pot of coffee every day.”. “I drink 9–12 beers after I get home from work, every day.”. “We have been growing green beans in our garden and I think I ate too many the other day.”.

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?. Positive Blumberg sign. Presence of pain at McBurney point. Positive Murphy sign. Positive Psoas sign.

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?. “How much alcohol do you drink?”. “Do you have pain after eating?”. “When was your last bowel movement?”. “Have you ever had splenomegaly?”.

The nurse is completing discharge instructions for a client admitted with esophagitis. Which client statements indicate the need for further education? Standard Text: Select all that apply. “I’m going to talk to my doctor about a nicotine patch.”. “I can do all of this stuff you’re talking about as long as I don’t have to give up my beer.”. “I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle.”. “The root of this problem is that I just sleep too much.”. “I told my wife to stop making serving me all of those vegetables.”.

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 disorder does the nurse suspect based on these findings?. Cholecystitis. Duodenal ulcer. Gastritis. Pancreatitis.

The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse notes that the liver span is approximately 11 centimeters. How will the nurse document this finding in the medical record?. Hepatomegaly. A normal finding. Related to recent diagnosis of chronic bronchitis. Presence of ascites.

The nurse is completing an abdominal assessment and is percussing over the left side of the upper portion of the client’s abdomen over the area of the stomach. The client states, “I haven’t had my breakfast, yet.” Based on this statement, which does the nurse anticipate?. Dullness. Flatness. Tympany. Hyperesonance.

The nurse is documenting the findings of an abdominal assessment on a client and documents the following information, “pain noted during palpation at McBurney point.” How did the nurse elicit this response during the assessment?. The nurse lightly palpated the around the client’s umbilicus. The nurse pressed into the client’s abdomen and then pulled his hand back quickly. The nurse palpated over the client’s spleen. The nurse palpated the area between the client’s ileum and umbilicus in the client’s right lower quadrant.

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?. Borborygmi present. Hypoactive bowel sounds present. Bruit present. Friction rub present.

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? Standard Text: Select all that apply. Constipation. Appendicitis. Cholecystitis. Small bowel obstruction. Peritonitis.

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

The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. As the nurse inspected the client’s abdomen and notes ascites. Based on this data, which interventions will the nurse perform next? Standard Text: Select all that apply. Obtain stool specimen for occult blood. Measure the client’s abdominal girth. Obtain stool specimen for culture and sensitivity. Bilateral leg measurements. Percuss the abdomen at midline.

The client’s current body weight is 342 pounds. The nurse wants to calculate the client’s body mass index (BMI). What is the client’s current weight in kilograms? ______ kilograms. Standard Text: Record answer rounded to the nearest tenth place. 155.5 kilograms. N/A.

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?. Infection. Umbilical hernia. Ventral hernia. Hiatal hernia.

he nurse is performing an abdominal assessment on the client. Rank the assessment steps in the order in which they should occur. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. 1.Percuss the abdomen. 2.Visualize the quadrants of the abdomen. 3.Palpate the abdomen. 4.Auscultate the abdomen. 5.Encourage the client to void. Correct Answer: 5, 2, 4, 1, 3.

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

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?. Hepatitis A virus. Hepatitis B virus. Hepatitis C virus. Hepatitis D virus.

The nurse is preparing an educational presentation regarding the Healthy People 2020 objectives. Which topics are appropriate and related to the objectives? Standard Text: Select all that apply. Educate pregnant women regarding the importance of small, more frequent dry meals throughout the day to reduce nausea and vomiting. Educate Asian men about the importance of avoiding alcohol because this is a population that is prone to alcohol abuse. Educate people who are anticipating traveling to India, Asia, Africa, or Central America about ways to reduce their risk of becoming infected with hepatitis E virus. Educate immunocompromised populations and those caring for them about the importance of safe food handling. Educate people about the relationship between regular, thorough oral hygiene practices and good nutrition.

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? Standard Text: Select all that apply. Schedule the client for an endoscopy as ordered. Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider. Educate the client regarding Helicobacter pylori infections. Discuss the importance of using over-the-counter aspirin for mild pain relief. Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer.

An adolescent client is seen for abdominal pain in the local clinic. The client states, “The pain is sort of all over my belly. I can’t really find one place that hurts more than another area.” Based on the nurse’s understanding about disorders of abdomen and associated symptomatology, which nursing diagnoses are appropriate for this client? Standard Text: Select all that apply. Acute pain. Hypothermia. Diarrhea. Altered urinary elimination. Altered nutrition, less than body requirements.