During deep palpation of the client's abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following actions would be most appropriate?
D) Document the position of the liver.
When reviewing the medications currently taken by a 50-year-old client who is complaining of constipation, teaching is indicated when the nurse notes which medication?
D) Vitamin supplement with iron
A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The studentsdemonstrate understanding of the proper sequence when they demonstrate the techniques in which order?
C) Inspect, auscultate, percuss, palpate
To promote relaxation of the client's abdominal muscles, which of the following would be most appropriate for the nurse to do?
B) Place a pillow under both of the client's knees.
A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion?
B) Cullen's sign
A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following?
C) Absent
The nurse is percussing a client's liver and is assessing liver descent. The nurse should have the client do which of the following?
D) Hold the breath
A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following?
B) It is a normal-sized liver.
Which of the following should a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?
D) Splenomegaly
While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following?
C) Infection
The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location?
B) Deep epigastrium to the left of midline
During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take?
C) Stop palpating and get medical assistance
A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation?
C) Right side-lying
A client's bladder is found to be distended. At which location should the nurse begin palpating?
A) At the symphysis pubis
The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?
B) Right lower quadrant
The nurse demonstrates the correct technique for assessing the psoas sign by which action?
B) Flexing the client's right hip, applying downward pressure on the right thigh
The nurse is assessing a client who is in liver failure and who has developed ascites. When measuring the client's abdominal girth, the nurse should place the client in which position?
A) Standing
A nurse is reviewing the various causes associated with abdominal distention. Which of the following should the nurse identify? Select all that apply.
A) Fat
B) Stool
C) Gas
D) Hernia
E) Fibroid tumors
A) Fat
B) Stool
E) Fibroid tumors
A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse should document which of the following?
B) Positive Rovsing's sign
The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?
A) ìI'm going to examine the area where you're having pain first to get a better picture
of what's going on.î
B) ìBefore I get ready to examine the painful area, I will let you know in plenty of
time.î
C) ìYou don't need to worry about anything. I will make sure to be very gentle during
the exam.î
D) ìSince you're having pain in a certain area, I won't have to do a very detailed exam
there.î
B) ìBefore I get ready to examine the painful area, I will let you know in plenty of
time.î
The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?
A) Absorbing large amounts of water
A client exhibits many of the most common signs and symptoms of peptic ulcer disease.What interview question addresses the most plausible cause of the client's health problem?
C) ìDo you take painkillers like aspirin on a regular basis?î
An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide?
C) Quit smoking as soon as possible.
A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor?
A) Overuse of laxatives
The nurse is inspecting a new client's abdomen and notes the presence of a tight,distended abdomen and visible arterioles on the abdominal skin surface. How should thenurse proceed with assessment?
C) Assess the client for other signs and symptoms of liver disease
The nurse is assessing the gastrointestinal system of an 81-year-old client. What age related change should the nurse consider when collecting and analyzing assessment
data?
A) The client is more vulnerable to impaired nutrition due to decreased appetite.
B) The client derives less nutritional value from food because of decreased enzyme
production.
C) The client's liver will be significantly larger than that of a younger client.
D) The client will have greater bowel motility than a younger adult.
A) The client is more vulnerable to impaired nutrition due to decreased appetite.
The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?
A) Repeat auscultation in four to six hours.
B) Palpate the client's abdomen to stimulate bowel motility.
C) Perform abdominal percussion, wait three to five minutes and then repeat
auscultation.
D) Listen for at least five minutes before documenting an absence of bowel sounds.
D) Listen for at least five minutes before documenting an absence of bowel sounds.
The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?
D) Tympany
The nurse is performing blunt percussion of a client's kidneys. For what abnormal finding is the nurse primarily assessing?
B) Tenderness
The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment?
