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Health Assessment > Abdomen (Chapter 22) > Flashcards

Abdomen (Chapter 22) Flashcards

1
Q

what is the order for abdomen assessment

A

inspection
auscultation
percussion
palpation

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2
Q

what organs fall under the solid viscera

A

liver
panceras
spleen
adrenal glands
kidneys
ovaries
uterus

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3
Q

what organs fall under the hollow viscera

A

stomach
gall bladder
small inestine
colon
bladder

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4
Q

hollow visera shape depends on

A

content

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5
Q

divide the abdomen into how many quadrants

A

4

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6
Q

what direction do you proceed when going through the quadrants

A

clockwise

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7
Q

why is the sequence of the abdomen assessment different than other systems

A

so you do not disrupt internal contents

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8
Q

the liver is in what quadrant

A

RUQ

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9
Q

the sigmoid colon is in what quadrant

A

LLQ

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10
Q

the bladder is in what quadrants

A

in the middle between RLQ and LLQ

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11
Q

what quadrant is the gallbladder in

A

RUQ

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12
Q

what quadrant is the spleen in

A

LUQ

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13
Q

what quadrant is the majority of the stomach in

A

LUQ

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14
Q

what quadrant is the appendix in

A

RLQ

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15
Q

why is one kidney lower than the other, what kidney is lower

A

the right kidney is lower due to the liver

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16
Q

what is the costovertebral angle found between

A

12th rib and spine

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17
Q

RUQ

A

right upper quadrant

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18
Q

LUQ

A

left upper quadrant

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19
Q

RLQ

A

right lower quadrant

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20
Q

LLQ

A

left lower quadrant

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21
Q

what quadrant would you start at because this is where bowel sounds first start after they have been absent

A

right lower quadrant
illocecal valve

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22
Q

dysphagia

A

difficulty swallowing

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23
Q

what is the best position to have the patient in when doing the abdominal assessment. why?

A

supine and flat
allows to see extension of the abdomen

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24
Q

what should you do if the patient claims they have areas of tenderness and pain

A

assess that area last

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25
Q

why do we assess the surgical scars, especially new ones

A

because there is a risk for infection

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26
Q

what should we do to our stethoscope before auscultation

A

warm it

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27
Q

does the older adult have decreased or increased salvia amounts

A

decreased

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28
Q

does the older adult have decreased or increased sense of taste

A

decreased

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29
Q

does the older adult have decreased or increased use of salt and sugar

A

increased

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30
Q

does the older adult have delayed or faster esophageal emptying

A

delayed

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31
Q

since the older adult has delayed esophageal emptying that increases their risk for

A

aspiration

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32
Q

does the older adult have decreased or increased gastric acid secretion

A

decreased

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33
Q

what anemia are older adults at risk for

A

pernicious

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34
Q

absorption of what mineral may be problematic

A

ca+

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35
Q

older adults have increased incidence of what

A

gallstones

36
Q

what could cause a lack of symmetry in a persons abdomen

A

bowel obstruction

37
Q

where would you note pulsations/movement

A

below xiphoid process

38
Q

is seeing pulsations normal?

A

can be normal
in pregnant women

39
Q

when would a pulsation not be good

A

AAA
abdmoninal aortic ansyersym

40
Q

bruit is caused by

A

stenosis

41
Q

if you have decreased hair this could be caused by

A

decreased nutrients

42
Q

what is the correct term for obese patient contour of abdomen

A

protuberant

43
Q

what could cause abdominal distension

A

bulges and masses
hernia
obesity
air or gas
ascites
feces

44
Q

ascities

A

edema in abdominal region

45
Q

ascites can be accompanied by

A

renal failure and use of peritoneal dialysis

46
Q

what part of stethoscope do we use for the bowel sounds

A

diaphragm

47
Q

normal bowl sounds

A

high pitches, gurgling, cascading, IRREGULAR, 5-30 per min

48
Q

hypoactive

A

<5 min

49
Q

hyperactive

A

> 30 min

50
Q

how long do we listen to determine normal/hypo/hyper

A

no set amount of time, the amount of time for you to assess

51
Q

if we have a patient with absent bowl sounds how long do we have to listen to make this determination

A

5 mins

52
Q

why might someone have absent bowl sounds

A

NPO

53
Q

where do you auscultate the aorta

A

midline under xiphoid process, above belly button

54
Q

where do you auscultate the renal arteries

A

above belly button laterally

55
Q

where do you auscultate the iliac arteries

A

below belly button laterally

56
Q

what part of the stethoscope do we use to listen do vascular sounds

A

bell

57
Q

what is normal when listening to vascular sounds

A

normal not to hear anything

58
Q

what is a bruit

A

abnormal
caused by stenosis of an artery that results in turbulent blood flow

59
Q

what pattern should you use when percussing

A

zigzag side ways bc that is the way the intestines flow

60
Q

what should be the dominate sound produced in the abdomen

A

tympany

61
Q

where would you hear a dull sound

A

over organs

62
Q

where would you hear a flat sound

A

over bone

63
Q

what are the tests used for ascites to confirm abnormal fluid

A

testing for fluid wave
testing for shifting dullness

64
Q

would you be able to feel the enlarged liver and nodule liver with light or deep palpations

A

light

65
Q

what enlarged organs would have to be felt with deep palpations

A

spleen and kidney

66
Q

do you start with light or deep palpation

A

light palpation and then deep palpation

67
Q

when enlarged liver it can extend below

A

the ribs

68
Q

rebound tenderness is called what sign

A

blumbergs

69
Q

rebound tenderness

A

peritoneal inflammation associated with appendicitis

70
Q

rebound tenderness is pain when

A

pressure is released

71
Q

inspiratory arrest is called what sign

A

Murphys sign

72
Q

inspiratory arrest is a test for

A

inflamed gallballder

73
Q

CVT

A

posterior percussion over kidneys

74
Q

striae is associated with

A

ascites

75
Q

umbilical hernia

A

usually intestine, belly button, have the person cough

76
Q

epigastric hernia

A

epigastric region, felt and palpable when patient stands

77
Q

incisional hernia

A

can be anywhere there is an incision and seen sitting and standing

78
Q

rebound tenderness what organ

A

appendix

79
Q

Murphys sign what organ

A

gallbladder

80
Q

how might you tell if an abdomen with a rounded appearance is filled with fluid, gas, or mass

A

fluid wave
shifting dullness

81
Q

when the patient reports that a certain spot in the abdomen is tender it is best to
A. palpate that spot last, to prevent pain from interfering with the rest of the examination
B. palpate that spot first, to avoid prolonging the patients anticipation
C. avoid that spot entirely, as other clinicians are going to palpate it after you
D. palpate in the same order as you always would, to avoid missing something because you broke your routine

A

A. palpate that spot last, to prevent pain from interfering with the rest of the examination

82
Q

which of the following is not in the list of common causes for abdominal distension
A. flatus
B. fetus
C. fluid
D. Follicles
E. Fat

A

D. Follicles

83
Q

which of the following answers are true (SATA)
A. listen for bowel sounds in each quadrant
B. Always auscultate before palpating as palpation may alter bowel sounds
C. Use the bell of stethoscope to auscultate for bowel sounds
D. Listen for at least 5 mins before documenting that bowl sounds are absent

A

A, B, D

84
Q

the patient has hypoactive bowel sounds. the nurse knows that a potential cause of hypoactive bowel sounds is
A. diarrhea
B. Peritonitis
C. Laxative use
D. Gastroenteritis

A

B. Peritonitis

85
Q

when examining a patent with good muscle wall relaxation the nurse observes abdominal pulsations between the xiphoid and umbilicus, the nurse would suspect that there are
A. pulsations of the renal arteries
B. pulsations of the inferior vena cava
C. normal abdominal aortic pulsations
D. increased peristalsis from a bowel obstruction

A

C. normal abdominal aortic pulsations

Health Assessment (20 decks)

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