Week #8: Abdominal Flashcards
Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area, a rough grating noise is heard. What is this sound?
A splenic rub
A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse’s first action?
Ask the client when the pain began
A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea & vomiting. What assessment technique will elicit kidney pain?
Blunt percussion of CVA tenderness
As part of an abdominal assessment, the nurse must palpate a client’s liver. In which quadrant is this organ located?
Right Upper Quadrant
What is the second step of physical assessment when assessing the abdomen?
Auscultation
The nurse is auscultating a client’s abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?
Listen for 5 minutes before documenting an absence of bowel sounds
When assessing risk of colon cancer, which of the following health-history components should the nurse prioritize?
Family history & dietary habits
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit
How many quadrants is the abdomen divided in to during an assessment?
4
An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits “Rovsing’s sign.” What medical diagnosis is associated with the assessment finding?
Appendicitis
Assessment used to assess for rebound tenderness to check for peritonitis; may include appendicitis or infection. Away from the painful area, push down your hand at a 90-degree angle slowly and deeply, then quickly release the pressure
Blumberg sign
Increased bowel sounds that occur with diarrhea and early intestinal obstruction
Borborygmi
Collection of fluid in the abdomen
Ascites
Pain that results from inflammation of the peritoneum; usually severe and localized over the involved structure
Parietal pain
Pain that occurs in more distant sites innervated at approximately the same spinal level as the disordered structure
Referred pain
Pain that occurs when hollow organs are distended, stretched, or contract forcefully; difficult to localize
Visceral pain
Hold fingers beneath the liver border, apply mild pressure and ask the patient to take a deep breath. Assessing for gallbladder inflammation
Murphy Sign
With patient lying supine, lift the right leg straight up, keeping the knee straight. Push down over the lower part of the right thigh while the patient pushes up. This is performed when appendicitis is expected.
Iliopsoas Muscle Test
As a person ages, there is a decrease in thirst sensation, production of saliva, gastric motility, peristalsis, and liver & renal function.
a) True
b) False
a) True
On average, waste products of food ingested today are eliminated 48 hours later.
a) True
b) False
a) True
Patients who present with fever, chills, and leukocytosis, and ___________________ warrant a rapid assessment and referral to an acute care facility.
Rebound Tenderness
_______________ bowel sounds occur more than 30 gurgles per minute.
Hyperactive
Significant pain upon ____________ percussion at the costovertebral angle (CVA) is a positive sign and could be indicative of pyelonephritis or kidney stones.
Blunt
What order should nurses complete there abdominal assessment:
- Inspection
- Auscultation
- Percussion
- Palpation
