WorksheetsChapter 23: Assessing the Abdomen (HA)
Total questions: 62
Worksheet time: 32mins
While assessing an adult client’s abdomen, the nurse observes that the client’s umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible
umbilical hernia.
ascites.
intra-abdominal bleeding.
pancreatitis.
Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?
Peptic ulcer
Cholecystitis
Pancreatitis
Appendicitis
A student nurse is auscultating for bowel sounds on a client who returned from surgery 48 hours ago. The student tells the charge nurse that she cannot hear bowel sounds in the lower quadrants. What is the appropriate response by the charge nurse to this information?
"You need to call the health care provider immediately for orders."
"Did you listen for 5 minutes in all four quadrants of the abdomen?"
"The nasogastric tube is preventing you from hearing the bowel sounds correctly."
"It takes about 3 to 5 days after surgery for the bowel sounds to return completely."
The sigmoid colon is located in this area of the abdomen: the
left upper quadrant.
left lower quadrant.
right upper quadrant.
right lower quadrant.
A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend?
Avoid eating overcooked foods
Avoid excessive alcohol intake
Avoid taking pain medications with food
Avoid taking antacid medications
To palpate the spleen of an adult client, the nurse should
ask the client to exhale deeply.
place the right hand below the left costal margin.
point the fingers of the left hand downward.
ask the client to remain in a supine position.
The nurse notes that a client experiencing right lower quadrant abdominal pain when the hip and knee are flexed, and the leg is rotated internally and externally. What should the nurse suspect is occurring with this client?
Appendicitis
Peritoneal irritation
Liver inflammation
Inflamed gall bladder
Which of the following assessment findings would need to be reported the physician immediately?
Constipation
Absent bowel sounds, vomiting undigested food
Chest fullness, heartburn and nausea after eating
Diarrhea and flatus
The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible
liver disease.
abdominal distention.
internal bleeding.
Cushing syndrome.
The nurse is caring for a client being treated for a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part?
Esophagus
Small intestine
Descending colon
Oropharynx
The nurse plans to assess a client’s liver border. Which area of the abdomen is the nurse going to assess?
RUQ
LUQ
RLQ
LLQ
When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?
Abdominal aortic aneurysm
Abdominal tumor
Ascites
Inflammation
The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible
aortic aneurysm.
paralytic ileus.
gastroenteritis.
fluid and electrolyte imbalances.
What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen?
Epigastric
Hypogastric
Hypochondriac
Inogastric
The client would complain of pain in what quadrant if experiencing appendicitis?
RUQ
RLQ
LUQ
LLQ
r
A nurse receives an order to measure the abdominal girth daily on a client admitted with ascites. How should the nurse best implement this order?
Have the client lying down in the bed with the head of bed slightly elevated
Any time of day is acceptable when using the umbilicus as a starting point
Measure at the same time each day, ideally in the morning after voiding
Elevate the head of bed to concentrate the fluid in one area of the abdomen
A client complains of abdominal pain that is worsened when he lies on his back. The nurse should suspect which of the following as the underlying cause?
Crohn's disease
Gastric ulcer
Pancreatitis
Gastroesophageal reflux
You are assessing a client for acute cholecystitis. What sign would you assess for?
Psoas sign
Obstipation sign
Murphy sign
Cutaneous hyperesthesia
While auscultating rushes of high-pitched bowel sounds a client complains of abdominal pain. What should the nurse suspect is occurring with this client?
ileus
diarrhea
peritonitis
intestinal obstruction
Diagnostic tests completed validate that a client has an obstruction of the ascending and transverse colon. Where should the nurse assess for bowel sounds around the obstruction?
LUQ
LLQ
RUQ
RLQ
l
A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process?
Internal adhesions from previous surgery
Intestinal obstruction at the sigmoid colon
Acute onset of appendicitis with possible rupture
Peritonitis from a ruptured diverticulum
A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regard to this finding?
“Have you been pregnant?”
“Are you experiencing any abdominal pain?"
“Have you noticed any color change to the skin?"
“Do you have high blood pressure?”
A nurse examines a client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of the client's abdomen?
Absent
Hyperactive
Borborygmus
Erratic
The nurse assess for kidney tenderness at what location?
Costovertebral angle
Midclavicular line
Hypogastric area
Umbilical region
The nurse is planning to assess a client’s abdomen. Which assessment technique should the nurse use after inspecting the area?
percussion
auscultation
light palpation
deep palpation
The nurse is planning to assess a client’s abdomen for rebound tenderness. The nurse should
perform this abdominal assessment first.
ask the client to assume a side-lying position.
palpate lightly while slowly releasing pressure.
palpate deeply while quickly releasing pressure.
A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause?
Crohn's disease
Gastric ulcer
Pancreatitis
Gastroesophageal reflux
A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?
Crohn's disease
Gastric ulcer
Pancreatitis
Gastroesophageal reflux
The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant with right flank pain. Which assessment should the nurse conduct next?
Palpate the right lower quadrant for rebound tenderness.
Test for a fluid wave.
Assess for Murphy's sign.
Assess for the obturator sign.
What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?
Ensure that the client has had a full meal before measuring the abdomen
Ask the client to be seated and relaxed when taking the measurement
Inform the client that the pen mark on the abdomen should not be washed off
Place the tape measure behind the client and measure at the umbilicus
The nurse explains to the client the main function of the stomach is to do what? Select all that apply.
Store food
Churn food
Absorb nutrients
Digest food
Absorb salt and water
A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client?
Ineffective Nutrition: Less Than Body Requirements
Constipation related to decrease in fluid intake
Ineffective Health Maintenance
Risk for Fluid Volume Deficit
How should the nurse perform blunt percussion over the liver?
Place left hand on right lower rib cage, strike it with ulnar side of right fist
Place right hand on mid of the rib cage; strike it with ulnar side of left fist
Place left hand on right lower rib cage, strike it with radial side of right fist
Place right hand on mid of the rib cage; strike it with ulnar side of left fist
During an assessment, the client describes vomiting moderate amounts that "smell like poop." The nurse might suspect
small bowel obstruction
gastric varices
hypercalcemia
irritable bowel syndrome
A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse?
Document the absence of bowel sounds
Assess for findings of dehydration
Listen for a total of 5 minutes
Palpate for abdominal rigidity
A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement?
Palpate the abdomen
Auscultate for bowel sounds
Measure abdominal girth
Perform percussion for tympany
Your client describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your client?
Malabsorption syndrome
Lactose intolerance
Crohn disease
Ulcerative colitis
The nurse would assess for positive Blumberg sign how?
Applying blunt pressure that the midclavicular line (MCL)
Applying blunt pressure at the costovertebral angle (CVA)
Applying and releasing pressure to the abdomen
Having the client breathe deeply
The nurse is assessing the client and performs the assessment shown. What is the nurse assessing?
Liver
Spleen
Right kidney
Ascending colon
The nurse is assessing the abdomen of a client. While percussing the abdomen, what normal sound does the nurse expect to hear?
Tympany
Dullness
Hollow sound
Friction rub
When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)
Murphy sign
Psoas sign
Obfuscator sign
Rovsing sign
Cutaneous hyperesthesia
During a physical examination of an adult client, the nurse is preparing to auscultate the client’s abdomen. The nurse should
palpate the abdomen before auscultation.
listen in each quadrant for 15 seconds.
use the diaphragm of the stethoscope.
begin auscultation in the left upper quadrant.
Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?
Spleen
Pancreas
Gallbladder
Liver
The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates?
Inflammation of the gallbladder
Appendicitis
Kidney pain
Peritonitis
The pancreas of an adult client is located
below the diaphragm and extending below the right costal margin.
posterior to the left midaxillary line and posterior to the stomach.
high and deep under the diaphragm and can be palpated.
deep in the upper abdomen and is not normally palpable.
During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document this finding?
relieving factors
associated manifestations
characteristic symptoms
onset
The nurse notes that a client’s abdominal skin is pale and taut. What should the nurse suspect is causing this finding?
Inflammation of the liver
Bleeding within the abdominal wall
Obstruction of the inferior vena cava
Fluid accumulating in the abdominal cavity
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant?
right upper
left upper
right lower
left lower
Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely?
Colon cancer
Cholecystitis
Inflammatory bowel disease
Irritable bowel syndrome
A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ?
Kidney
Liver
Spleen
Gallbladder
Which nursing diagnosis is most appropriate for an elderly client with poor dentition?
Risk for Imbalanced Nutrition: Less Than Body Requirements
Constipation
Fluid volume deficit
Diarrhea
While assessing the abdominal sounds of an adult client, the nurse hears high-pitched tinkling sounds throughout the distended abdomen. The nurse should refer the client to a health care provider for possible
intestinal obstruction.
gastroenteritis.
inflamed appendix.
cirrhosis of the liver.
The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain?
Discomfort
Dysphagia
Dyspepsia
Odynophagia
Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is
usually difficult to localize
right or left sided
more severe than parietal pain
also called referred pain
An older adult client who is admitted to the hospital with acute confusion has urinary incontinence. The nurse can accurately document this as which type of incontinence?
functional
overflow
stress
urge
The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by
Congestive heart failure and pyelonephritis
Cirrhosis and nephrosis
Metastatic neoplasms and coronary artery disease
Congestive heart failure and coronary artery disease
The nurse percusses the lowest interface in the left anterior axillary line, asks the client to take a deep breath, and percusses again. The nurse is assessing for which of the following?
Kidney tenderness
Splenic percussion sign
Splenic percussion sign
Tenderness of a nonpalpable liver
A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10-year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time?
Inspect the abdomen for color, shape, and symmetry
Obtain a complete set of vital signs and pain assessment
Listen with the bell of the stethoscope for vascular sounds
Observe for evidence of increased abdominal girth
During the abdominal examination, a nurse supports the client's right knee and ankle. The nurse flexes the client's hip and rotates the leg externally and internally. At this point, the client reports pain in the right lower quadrant. This test is positive for which sign?
Obturator
Psoas
Murphy's
Rovsing's
The nurse performs the assessment technique shown. What is the nurse assessing in this client?
Liver size
Colon obstruction
Engorged pancreas
Distended gall bladder
Which of the following acute abdominal symptoms could be life threatening?
Abdominal pain
Striae
Kidney stones
Indigestion
The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what?
Appendicitis
Inflammation of the gallbladder
Liver engorgement
Kidney pain
