ABDOMEN Flashcards
(10 cards)
When performing an abdominal assessment, in which order should the nurse proceed?
A. Inspection, percussion, palpation, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, palpation, percussion, inspection
D. Palpation, inspection, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
Rationale: Auscultation is performed before percussion or palpation to avoid altering bowel sounds.
A nurse auscultates the abdomen and does not hear any bowel sounds. How long should the nurse listen before documenting absent bowel sounds?
A. 30 seconds
B. 1 minute
C. 2 minutes per quadrant
D. 5 minutes total
D. 5 minutes total
Rationale: Bowel sounds are considered absent only after listening for 5 full minutes with no sound heard in any quadrant.
Which finding during abdominal palpation should the nurse recognize as abnormal?
A. Soft, non-tender abdomen
B. Mild tenderness over the sigmoid colon
C. Firm, board-like abdomen
D. Audible gurgling sounds during palpation
C. Firm, board-like abdomen
Rationale: A board-like abdomen may indicate peritonitis and requires immediate medical attention.
Which of the following is the most appropriate technique for assessing liver size?
A. Deep palpation of the right lower quadrant
B. Percussion along the midclavicular line
C. Inspection of the abdomen while the client breathes deeply
D. Auscultation for a friction rub
B. Percussion along the midclavicular line
Rationale: Liver span is estimated by percussing along the midclavicular line from resonance to dullness.
The nurse is performing light palpation of the abdomen. What is the correct depth to press?
A. 0.5 cm
B. 1–2 cm
C. 3–4 cm
D. 5–6 cm
B. 1–2 cm
Rationale: Light palpation is used to detect surface characteristics and tenderness, typically at a depth of 1–2 cm.
A client complains of right lower quadrant pain. Which action should the nurse take first during the abdominal assessment?
A. Palpate the painful area first
B. Avoid palpating the painful quadrant
C. Palpate the painful area last
D. Ask the client to bear down while palpating
C. Palpate the painful area last
Rationale: To prevent guarding and discomfort, the painful area should be palpated last.
The nurse notes visible peristaltic waves during abdominal inspection of a thin client. What should the nurse do next?
A. Document the finding as normal
B. Call the provider immediately
C. Palpate for rebound tenderness
D. Assess for signs of bowel obstruction
D. Assess for signs of bowel obstruction
Rationale: Visible peristalsis, especially with distention, may indicate a bowel obstruction.
During percussion of a client’s abdomen, the nurse notes a tympanic sound. What does this finding typically indicate?
A. Presence of fluid
B. Fecal matter
C. Air-filled intestine
D. Liver enlargement
C. Air-filled intestine
Rationale: Tympany is a normal finding over air-filled structures such as the intestines.
Which assessment finding would be most concerning in a patient with abdominal pain?
A. Hyperactive bowel sounds
B. Tenderness on light palpation
C. Rigid abdomen with guarding
D. Tympany on percussion
C. Rigid abdomen with guarding
Rationale: A rigid abdomen with guarding may indicate peritonitis or an acute abdomen, which is a medical emergency.
A nurse notes hypoactive bowel sounds in a postoperative patient. What is the best explanation for this finding?
A. Early sign of infection
B. Normal after abdominal surgery
C. Indication of constipation
D. Sign of increased peristalsis
B. Normal after abdominal surgery
Rationale: Hypoactive bowel sounds are common after surgery due to decreased peristalsis from anesthesia or pain medications.
