The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
The liver is located in the right upper quadrant (RUQ) and would elicit a dull percussion note
When percussing the left lower quadrant of the abdomen, the nurse elicits a drumlike sound normal for the:
c. Left kidney
d. Sigmoid colon
The sigmoid colon is a hollow organ located in the left lower quadrant of the abdomen. Tympanic (drumlike) sounds are usually heard on percussion of hollow viscera
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
a. Percuss and palpate in the lumbar region
b. Inspect and palpate in the epigastric region
c. Auscultate and percuss in the inguinal region
d. Percuss and palpate the midline area above the suprapubic bone
Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation
The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:
a. Increased salivation
b. Increased liver size
c. Increased esophageal emptying
d. Decreased gastric acid secretion
Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases
A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?
a. The spleen can be enlarged as a result of trauma.
b. Normally, the spleen is felt on routine palpation.
c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size.
d. An enlarged spleen should not be palpated because it can easily rupture
If an enlarged spleen is felt, then the nurse should refer the person and should not continue to palpate it. An enlarged spleen is friable and can easily rupture with over palpation
During inspection of a 52-year-old patient, the nurse notes that the patient’s abdomen is bulging and stretched with dullness percussed to the left lower quadrant. The nurse will document that the patient:
a. Is obese and on a weight loss program
b. Has a hernia and awaiting surgery
c. Has a scaphoid abdomen and there are no concerns
d. Has a protuberant abdomen, which requires further investigation
A protuberant abdomen is rounded, bulging, and stretched. A scaphoid abdomen caves inward. Protuberant abdomen and abdominal distension are abnormal
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a __________ profile.
Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane
While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these 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
Normally, the pulsations from the aorta are observed beneath the skin in the epigastric area, particularly in thin persons who have good muscle wall relaxation
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
c. Laxative use
Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited in peritonitis, paralytic ileus after abdominal surgery, or late bowel obstruction
During an abdominal assessment, the nurse would consider which of these findings as normal?
a. Presence of a bruit in the femoral area
b. Tympanic percussion note in the umbilical region
c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line
d. Dull percussion note in the left upper quadrant at the midclavicular line
Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally, the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).
An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:
a. Increased gastric acid secretion
b. Decreased gastric acid secretion
c. Delayed gastrointestinal emptying time
d. Increased gastrointestinal emptying time
Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium
A patient is complaining of a sharp pain along the costovertebral angle. The nurse is aware that this symptom is most often indicative of:
a. Ovary infection
b. Liver enlargement
c. Kidney inflammation
d. Spleen enlargement
Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area
During abdominal assessment, the nurse performs deep palpation to screen for:
a. Bowel motility
b. Changes in size of organs
c. Gastroesophageal reflux
d. Abdominal skin and musculature
With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses
During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by:
a. Projectile vomiting
b. Hypoactive bowel activity
c. Palpable olive-sized mass in the right lower quadrant
d. Pronounced peristaltic waves crossing from right to left
Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. An olive-sized mass can be palpated in the right upper quadrant (RUQ)
During abdominal assessment of an adult patient, the nurse auscultates a bruit in the upper abdomen area just left of the midline. The nurse will:
a. Palpate the area
b. Document the findings as normal
c. Report the findings immediately
d. Assess for rebound tenderness
If a bruit is heard on auscultation, the area should not be palpated, to avoid rupturing an abdominal aortic aneurysm. The findings should be reported immediately
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient’s abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least:
a. 1 minute
b. 5 minutes
c. 10 minutes
d. 2 minutes in each quadrant
Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent
A patient is suspected of having cholecystitis, or inflammation of the gallbladder. The nurse should conduct which of these techniques to assess for this condition?
a. Obturator test
b. Test for inspiratory arrest
c. Assess for rebound tenderness
d. Iliopsoas muscle test
Normally, palpation of the liver causes no pain. In a person with cholecystitis, or inflammation of the gallbladder, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration. The person feels sharp pain and abruptly stops midway during inspiration; this is termed inspiratory arrest (Murphy’s sign)
Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?
a. Dullness across the abdomen
b. Flatness in the RUQ
c. Hyper-resonance in the left upper quadrant
d. Tympany in the right and left lower quadrants
A large amount of ascitic fluid produces a dull sound on percussion
When palpating the abdomen of a 20-year-old patient who was injured in a motor vehicle accident, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?
b. Sigmoid colon
The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the RUQ, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.
The nurse is assessing a 60-year-old male patient with sharp upper abdominal pain. What additional finding during history taking indicates possible peptic ulcer disease?
a. Lactose intolerance
b. Streptococcal infections
c. Recurrent constipation with frequent laxative use
d. Frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs)
Peptic ulcer disease increases with age and occurs with frequent use of NSAIDs, excessive alcohol consumption, smoking, and infection by Helicobacter pylori. Eight to 10 million Canadians have H. pylori infection, which is also associated with development of stomach cancer; approximately 75% of Indigenous peoples are infected by H. pylori
During assessment of a patient with chronic emphysema, the nurse recognizes that percussing the liver border below the right costal margin:
a. Can indicate liver cirrhosis
b. Indicates hepatomegaly
c. Requires immediate reporting of findings
d. Is an expected finding in this patient
For people with chronic emphysema, the liver is displaced downward by the hyperinflated lungs. Although a dull percussion note can be heard well below the right costal margin, the overall span is still within normal limits. Hepatomegaly refers to an enlarged live
During an assessment, the nurse notices that a 6-month-old patient’s umbilicus is enlarged and everted. It is positioned midline with no change in skin colour. The nurse recognizes that the patient may have which condition?
a. Intra-abdominal bleeding
c. Umbilical hernia
d. Abdominal tumour
The umbilicus is normally at midline and inverted with no signs of discoloration. With umbilical hernia, the mass is enlarged and everted. The soft, skin-covered mass is the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring. It is accentuated by increased intra-abdominal pressure, which occurs with crying, coughing, vomiting, or straining, but the bowel rarely becomes incarcerated or strangulated. It is more common in infants of African or Asian descent and in premature infants. Most umbilical hernias resolve spontaneously by age 1 year.
During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:
b. Distended bladder
ANS: D If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation
During the health history, the patient tells the nurse, “I have pain all the time in my stomach. It’s worse 2 hours after I eat, but it gets better if I eat again!” On the basis of these symptoms, the nurse suspects that the patient has which condition?
b. Gastric ulcer
c. Duodenal ulcer
Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may be relieved by more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis
The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply.)
a. Test for Murphy’s sign
b. Test for Blumberg’s sign
c. Test for shifting dullness
d. Perform the iliopsoas muscle test
e. Test for fluid wave
ANS: B, D
Testing for Blumberg’s sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. Murphy’s sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites