Abdomen Ch20 Exam Questions - Health Assessment in Nursing 4e Test Bank by Cynthia Fenske. DOCX document preview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)
Chapter 20 Abdomen
- A client asks the nurse where their appendix is. Which response should the nurse provide?
1. "It is attached to the large intestine."
2. "It is attached to the sigmoid colon."
3. "It is attached to the large intestine at the cecum."
4. "It is attached to the small intestine at the cecum."
Page Ref: 427
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 20.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
- A client asks the nurse where their spleen is located. Which response should the nurse provide?
1. "Just above the umbilicus."
2. "Upper midline area of your abdomen."
3. "Right upper side of your abdomen."
4. "Left upper side of your abdomen."
Page Ref: 427
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 20.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
- 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? Select all that apply.
1. "It helps you digest fats."
2. "It is an endocrine and exocrine gland."
3. "It filters waste from the blood and makes urine."
4. "It makes some blood-clotting substances."
5. "It can help you store certain vitamins."
Page Ref: 426
Cognitive Level: Understanding
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 20.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
- The nurse is palpating the right upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply.
1. Liver.
2. Gallbladder.
3. Appendix.
4. Spleen.
5. Stomach.
Page Ref: 535
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.1: Describe the anatomy and physiology of the abdomen.
MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
- A client asks the nurse, "What's the purpose of a gallbladder anyway? My mom lived for many years without her gallbladder." Which information would be beneficial for the nurse to share with this client?
1. "You are right. We still don't know the function of the gallbladder."
2. "It stores bile until it is needed for digestion of fats."
3. "It destroys old red blood cells."
4. "It helps you digest carbohydrates by producing enzymes."
Page Ref: 431
Cognitive Level: Understanding
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
- The nurse is palpating the left upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply.
1. Liver.
2. Gallbladder.
3. Appendix.
4. Spleen.
5. Stomach.
Page Ref: 431
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen.
MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
- The nurse is mapping the client's abdomen into four quadrants. Which landmarks would the nurse use to perform this assessment? Select all that apply.
1. Umbilicus.
2. Midclavicular lines.
3. Xiphoid process.
4. Lower border of the right ribs.
5. Iliac crests.
Page Ref: 429 and 430
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen.
MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
- The nurse is preparing to assess the abdomen of a client suspected of having an appendicitis. Which should the nurse include in the plan for the abdominal assessment?
1. Avoid palpation.
2. Palpate the area last.
3. Percuss the area first.
4. Auscultate the area first.
Page Ref: 442
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
- 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? Select all that apply.
1. "It is a little cool in our examination room; may I turn up the thermostat?"
2. "I've been told you are experiencing some pain in the lower right area of your abdomen. I will examine that area first."
3. "I am going to stand on your left side so I can feel your liver better."
4. "I'm going to place this drape over you so you don't feel too exposed during this examination."
5. "I am going to place this pillow behind your head and this pillow under your knees."
Page Ref: 439
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen.
MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
- The nurse is performing an abdominal assessment on a client. During the focused interview, the client tells the nurse about recently experiencing abdominal pain. As the nurse assesses the client, which behaviors indicate that the client may be experiencing pain or anxiety during the examination? Select all that apply.
1. The client is diaphoretic.
2. The client moves away from the nurse's hands.
3. The client grimaces.
4. The client pulls his knees toward his stomach.
5. The client coughs loudly.
Page Ref: 439
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Basic Care and Comfort
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- 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 × 1012/L |
Temperature | 101.2 degrees Fahrenheit |
Blood pressure | 152/84 |
1. "I get home so late at night, but I've got to stop lying down right after dinner."
2. "I drink a whole pot of coffee every day."
3. "I drink 9-12 beers after I get home from work, every day."
4. "We have been growing green beans in our garden and I think I ate too many the other day."
Page Ref: 446
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- 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?
1. Positive Blumberg's sign.
2. Presence of pain at McBurney's point.
3. Positive Murphy sign.
4. Positive psoas sign.
Page Ref: 445
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 20.5: Generate the appropriate documentation to describe the assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- 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?
1. "How much alcohol do you drink?"
2. "Do you have pain after eating?"
3. "When was your last bowel movement?"
4. "Have you ever had splenomegaly?"
Page Ref: 443
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.3: Determine which questions about the abdomen to use for the focused interview.
MNL Learning Outcome: 20.2. Plan questions about the abdomen for the focused interview.
- The nurse is completing discharge instructions for a client admitted with esophagitis. Which client statements indicate the need for further education? Select all that apply.
1. "I'm going to talk to my doctor about a nicotine patch."
2. "I can do all of this stuff you're talking about as long as I don't have to give up my beer."
3. "I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle."
4. "The root of this problem is that I just sleep too much."
5. "I told my wife to stop making serving me all of those vegetables."
Page Ref: 450
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- 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 question should the nurse include in the history?
1. "Do you have a history of cholecystitis?"
2. "Do you have a history of a duodenal ulcer?"
3. "Do you have a history of gastritis?"
4. "Do you have a history of pancreatitis?"
Page Ref: 436 and 446
Cognitive Level: Analyzing
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 20.3: Determine which questions about the abdomen to use for the focused interview.
MNL Learning Outcome: 20.2. Plan questions about the abdomen for the focused interview.
- The nurse is performing reviewing the risk factors for colorectal cancer with a client. Which information should the nurse include? Select all that apply.
1. Stress.
2. Smoking.
3. Diabetes.
4. Obesity.
5. Diet high in red meat.
Page Ref: 450
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
- The nurse is preparing to percuss over the left upper portion of the client's abdomen. The client states, "I haven't had my breakfast, yet." Based on this statement, which does the nurse anticipate?
1. Dullness.
2. Flatness.
3. Tympany.
4. Hyperresonance.
Page Ref: 447
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
- The nurse documents "pain noted during palpation at McBurney's point." Which describes the techniques used during the assessment?
1. The nurse lightly palpated the around the client's umbilicus.
2. The nurse pressed into the client's abdomen and then pulled his hand back quickly.
3. The nurse palpated over the client's spleen.
4. The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant.
Page Ref: 444
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen.
MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
- 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?
1. Borborygmi present.
2. Hypoactive bowel sounds present.
3. Bruit present.
4. Friction rub present.
Page Ref: 441
Cognitive Level: Understanding
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 20.5: Generate the appropriate documentation to describe the assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- 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? Select all that apply.
1. Constipation.
2. Appendicitis.
3. Cholecystitis.
4. Small bowel obstruction.
5. Peritonitis.
Page Ref: 445
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- The nurse is auscultating the abdomen of a client for vascular sounds. The nurse hears a soft, continuous humming sound. Based on this data, the nurse suspects dysfunction with which organ?
1. Stomach.
2. Spleen.
3. Pancreas.
4. Liver.
Page Ref: 446
Cognitive Level: Analyzing
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. The nurse inspected the client's abdomen and notes ascites. Based on this data, which interventions will the nurse perform next? Select all that apply.
1. Obtain stool specimen for occult blood.
2. Measure the client's abdominal girth.
3. Obtain stool specimen for culture and sensitivity.
4. Bilateral leg measurements.
5. Percuss the abdomen at midline.
Page Ref: 448
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches/ | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- The nurse is preparing to assess a client newly diagnosed with stomach cancer. Which assessment findings should the nurse anticipate? Select all that apply.
1. Diarrhea.
2. Vomiting.
3. Gastrointestinal bleeding.
4. Abdominal distention.
5. Dark-colored urine.
Page Ref: 449
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- 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?
1. Infection.
2. Umbilical hernia.
3. Ventral hernia.
4. Hiatal hernia.
Page Ref: 449
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- The nurse is performing an abdominal assessment on the client. Rank the assessment steps in the order in which they should occur.
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.
Page Ref: 439-445
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen.
MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
- 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?
1. "This virus is transmitted by sexual contact with someone who already has been infected with this virus."
2. "Most likely, you ate something that was contaminated with the virus."
3. "It is spread by blood transfusions."
4. "Have you ever injected an illegal drug?"
Page Ref: 450
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
- 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?
1. Hepatitis A virus.
2. Hepatitis B virus.
3. Hepatitis C virus.
4. Hepatitis D virus.
Page Ref: 450
Cognitive Level: Understanding
Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
- The nurse has discussed the precipitating factors of pancreatitis with a client. Which statement made by the client indicates an understanding of the information?
1. "I will cut back on my drinking."
2. "I will no longer use acetaminophen."
3. "I am working with a dietician to reduce my weight."
4. "I am working to get my diabetes under control."
Page Ref: 447
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
- 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? Select all that apply.
1. Schedule the client for an endoscopy as ordered.
2. Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider.
3. Educate the client regarding Helicobacter pylori infections.
4. Discuss the importance of using over-the-counter aspirin for mild pain relief.
5. Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer.
Page Ref: 432
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen.
MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
- A client tells the nurse they are frequently under a great deal of stress. Which common gastrointestinal disorder should the nurse recognize the client is at risk for? Select all that apply.
1. Diverticulitis.
2. Duodenal ulcer.
3. Gastritis.
4. Gastroesophageal Reflux Disorder.
5. Irritable bowel syndrome.
Page Ref: 446, 447
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
MNL Learning Outcome: 20.2. Plan questions about the abdomen for the focused interview.