Abdominal assessment

The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain.

This test is used to confirm a(n):

a. Inflamed liver

b. Perforated spleen

c. Perforated appendix

d. Enlarged gallbladder

C

The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked

her from side to side. This finding would indicate:

a. Epigastric hernia

b. Pyloric obstruction

c. Hypoactive bowel sounds

d. Hyperactive bowel sounds

D

The nurse is conducting an abdominal assessment on a 52-year-old patient with ascites and a history of extensive alcohol use. During inspection what should the nurse expect to observe?

a. Scaphoid abdomen with visible fine veins

b. Abdominal distension with visible dilated abdominal veins

c. Flat abdomen with bulging hernia

d. Abdominal contraction with sunken umbilicus

B

Veins may become prominent and dilated with portal hypertension, cirrhosis, ascites, or vena caval obstruction. With ascites there is an increase in abdominal girth presenting in distension of the abdomen (see Chapter 22.)

The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?

a. Palpation of reportedly “tender” areas is avoided because palpation in these areas may cause pain.

b. Palpating a tender area is quickly performed to avoid causing any discomfort to the patient.

c. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths.

d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

ANS: D

Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue.

a. Turgor

b. Texture

c. Density

d. Consistency

ANS: C

Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation

When percussing over the liver of a patient, the nurse observes a dull sound. The nurse should:

a. Consider this a normal finding.

b. Palpate this area for an underlying mass.

c. Reposition the hands, and attempt to percuss in this area again.

d. Consider this an abnormal finding and refer the patient for additional treatment.

ANS: A

Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound.

The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?

a. Ask the patient to take deep breaths to relax the abdominal musculature

b. Consider this a normal finding and proceed with the abdominal assessment

c. Increase the amount of strength used when attempting to percuss over the abdomen

d. Decrease the amount of strength used when attempting to percuss over the abdomen

ANS: C

The thickness of the person’s body wall will be a factor. The nurse needs a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:

a. Warm the endpiece of the stethoscope by placing it in warm water.

b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination.

c. Ensure that the bell side of the stethoscope is turned to the “on” position.

d. Check the temperature of the room and offer blankets to the patient if he or she feels cold.

ANS: D

The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiner’s hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds.

During examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates:

a. Constipation

b. Air-filled areas

c. Presence of a tumour

d. Presence of dense organs

ANS: B

A musical or drumlike sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or the intestines.

The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? **(Select all that apply.)**

a. Warm the hands first before touching the patient.

b. For deep palpation, use one long continuous palpation when assessing the liver.

c. Start with light palpation to detect surface characteristics.

d. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps.

e. Identify any tender areas, and palpate them last.

f. Use the palms of the hands to assess temperature of the skin.

ANS: A, C, D, E

The hands should always be warmed before beginning palpation. Intermittent pressure rather than one long, continuous palpation is used; any tender areas are identified and palpated last. Fingertips are used to examine skin texture, swelling, pulsation, and the presence of lumps. The dorsa (backs) of the hands are used to assess skin temperature because the skin is thinner on the dorsa than on the palms

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

a. Dullness

b. Tympany

c. Resonance

d. Hyper-resonance

ANS: A

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:

a. Liver

b. Pancreas

c. Left kidney

d. Sigmoid colon

ANS: D

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

A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:

a. Aphasia

b. Dysphasia

c. Dysphagia

d. Anorexia

ANS: C

Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is loss of appetite

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

ANS: D

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

ANS: D

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.

ANS: D

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

ANS: D

A protuberant abdomen is rounded, bulging, and stretched (see Figure 22-7). A scaphoid abdomen caves inward. Protuberant abdomen and abdominal distension (see Table 22-1) are abnormal.

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a __________ profile.

a. Flat

b. Convex

c. Bulging

d. Concave

ANS: D

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 (see Figure 22-7).

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

ANS: C

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:

a. Diarrhea

b. Peritonitis

c. Laxative use

d. Gastroenteritis

ANS: B

Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited in peritonitis, paralytic ileus after abdominal surgery, or late bowel obstruction.

The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

a. “We need to determine the areas of tenderness before using percussion and palpation.”

b. “Auscultation prior prevents distortion of bowel sounds that might occur after percussion and palpation.”

c. “Auscultation allows the patient more time to relax and thus be more comfortable with the physical examination.”

d. “Auscultation prevents distortion of vascular sounds, such as bruits and hums, which might occur after percussion and palpation.”

ANS: B

Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would result in false interpretation of bowel sounds

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds:

a. Are usually loud, high-pitched, rushing, and tinkling sounds

b. Are usually high-pitched, gurgling, and irregular sounds

c. Sound like two pieces of leather being rubbed together

d. Originate from the movement of air and fluid through the large intestine

ANS: B

Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

a. Loud continual hum

b. Peritoneal friction rub

c. Hypoactive bowel sounds

d. Hyperactive bowel sounds

ANS: D

Borborygmi is the term used for hyperperistalsis when the person actually feels the stomach growling

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

ANS: B

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).

The nurse is assessing the abdomen of a pregnant woman who is complaining of having “acid indigestion” all the time. The nurse knows that esophageal reflux during pregnancy can cause:

a. Diarrhea

b. Pyrosis

c. Dysphagia

d. Constipation

ANS: B

Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:

a. Flatness, resonance, and dullness

b. Resonance, dullness, and tympany

c. Tympany, hyper-resonance, and dullness

d. Resonance, hyper-resonance, and flatness

ANS: C

Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyper-resonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, a mass, or solid organs, such as the liver.

The nurse notices that a patient has ascites, which indicates the presence of:

a. Fluid

b. Feces

c. Flatus

d. Fibroid tumours

ANS: A

Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer

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

ANS: B

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.

The nurse notices that a patient has black, tarry stools and recognizes that they could indicate:

a. Gallbladder disease

b. Iron supplementation

c. Gastrointestinal bleeding

d. Localized bleeding around the anus

ANS: C

Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding.

Red blood in stools occurs with localized bleeding around the anus. Stools may be black, but nontarry, with use of iron supplements

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?

a. Spleen

b. Sigmoid

c. Appendix

d. Gallbladder

ANS: C

The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true?

a. Abdominal tone is increased.

b. Abdominal musculature is thinner.

c. Abdominal rigidity with an acute abdominal condition is more common.

d. The older adult with an acute abdominal condition complains more about pain than the younger person.

ANS: B

In the older adult, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with an acute abdominal condition is less common in the aging person. The older adult with an acute abdominal condition often complains less about pain compared with a younger person.

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

ANS: A

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

ANS: C

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

ANS: B

Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent

ust before going home, a new mother asks the nurse about the infant’s umbilical cord. Which of these statements by the nurse is correct?

a. “It should fall off in 10 to 14 days.”

b. “It will soften before it falls off.”

c. “It contains two veins and one artery.”

d. “Skin will cover the area within 1 week.”

ANS: A

At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton’s jelly. The umbilical stump dries within a week, hardens, and falls off in 10 to 14 days. Skin will cover the area in 3 to 4 weeks.

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

ANS: A

A large amount of ascitic fluid produces a dull sound on percussion

A 40-year-old man states that his physician diagnosed him with a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?

a. “No need to worry. Most men your age develop hernias.”

b. “A hernia is a loop of bowel that has pushed through a weak spot in the abdominal muscles.”

c. “A hernia is the result of prenatal growth abnormalities that are just now causing problems.”

d. “I’ll have to have your physician explain this to you.”

ANS: B

The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall.

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should:

a. Document the presence of hepatomegaly

b. Ask additional health history questions regarding his alcohol intake

c. Describe this dullness as indicative of an enlarged liver and refer him to a physician

d. Consider this finding as normal and proceed with the examination

ANS: D

A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.

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?

a. Spleen

b. Sigmoid colon

c. Appendix

d. Gallbladder

ANS: A

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

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

ANS: D

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 liver.

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

b. Constipation

c. Umbilical hernia

d. Abdominal tumour

ANS: C

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. The other responses are incorrect

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:

a. Splenomegaly

b. Distended bladder

c. Constipation

d. Ascites

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.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:

a. Examine the tender area first

b. Examine the tender area last

c. Avoid palpating the tender area

d. Palpate the tender area first and then auscultate for bowel sounds

ANS: B

The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would result in false interpretation of bowel sounds.

When inspecting a patient’s abdomen, the nurse notes an old surgical scar at midline extending vertically below the umbilicus. The nurse will: **(Select all that apply.)**

a. Not be concerned with it because it is an old scar.

b. Ask the patient about the scar.

c. Not consider it relevant because the patient did not identify it.

d. Include a drawing of the scar’s location on the abdomen in the documentation.

e. Measure and record the length of the scar in the documentation.

ANS: B, D, E

If a scar is present, the patient should be asked about it, and a drawing of its location and length in centimetres should be included in the patient’s record (Figure 22-10). A surgical scar is an indication of the possible presence of underlying adhesions and excess fibrous tissue.