The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what?
A. Borborygmi
B. Bruit
C. Venous hum
D. Friction rub
B. bruit
Explanation: Bruits are swishing sound that indicate turbulent blood flow. Borborygmi is incr...
The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse
would document this sounds as a what?
A. Borborygmi
B. Bruit
C. Venous hum
D. Friction rub correct answersB. bruit
Explanation: Bruits are swishing sound that indicate turbulent blood flow. Borborygmi is increased bowel
sounds. A venous hum is a soft-pitched humming sound associated with partial obstruction of an artery
and reduced blood flow to the organ. Friction rubs are a grating sounds with inspiration.
A client visits the clinic for a routine examination. The client tells the nurse that she has become
constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client
about the use of iron preparations and possible constipation. The nurse determines that the client has
understood the instructions when she says
A. "Constipation should decrease if I take the iron tablets with milk."
B. "I should cut down on the number of iron tablets I am taking each day."
C. "I should discontinue the iron tablets and eat foods that are high in iron."
D. "I can decrease the constipation if I eat foods high in fiber and drink water." correct answersD. "I can
decrease the constipation if I eat foods high in fiber and drink water."
Explanation: High iron intake may lead to chronic constipation.
You are assessing a client for acute cholecystitis. What sign would you assess for?
A. Cutaneous hyperesthesia
B. Obstipation sign
,C. Psoas sign
D. Murphy sign correct answersD. Murphy Sign
Explanation: A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive
Murphy sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is
usually less well localized.
pg. 525
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. It is a vascular noise.
B. It is a variant of bowel noise.
C. It is a splenic rub.
D. It represents borborygmi. correct answersC. It is a splenic rub.
Explanation: A rough, grating noise over this area represents a splenic rub, which can accompany splenic
infarction. Rubs also occur over the liver and pleura and pericardium.
The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at
the
A. left upper quadrant.
B. costovertebral angle.
C. external oblique angle.
D. right upper quadrant. correct answersB. costovertebral angle.
explanation: Kidney tenderness is best assessed at the costovertebral angle.
The sigmoid colon is located in this area of the abdomen: the
,A. left lower quadrant.
B. left upper quadrant.
C. right upper quadrant.
D. right lower quadrant. correct answersA. left lower quadrant.
Explanation: The left lower quadrant (LLQ) contains the left kidney (lower pole), left ovary and tube, left
ureter, left spermatic cord, and descending and sigmoid colon.
-- sigmoid colon is the terminal portion of the large intestine
The nurse assesses a client's indwelling urinary catheter bag and observes cloudy urine. The client also
complains of lower back pain. What is the nurse's best action?
A. Flush the catheter tubing with sterile normal saline.
B. Encourage the client to increase PO fluid intake.
C. Prepare to obtain a urine specimen for culture.
D. Record the findings as expected for a client with an indwelling catheter. correct answersC. Prepare to
obtain a urine specimen for culture.
Explanation: The client is exhibiting symptoms of a catheter associated urinary tract infection. The nurse
should notify the healthcare provider and prepare to collect a urine specimen for culture. Increased fluid
intake can decrease complications of a UTI; however, a UTI must be treated with antibiotics as well.
Flushing the tubing with saline involves disrupting the sterility of the line and is not routinely performed
when suspecting a UTI.
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should:
A. ask the client to assume a side-lying position.
B. perform this abdominal assessment first.
C. palpate lightly while slowly releasing pressure.
, D. palpate deeply while quickly releasing pressure. correct answersD. palpate deeply while quickly
releasing pressure.
Explanation: If the client has abdominal pain or tenderness, test for rebound tenderness by palpating
deeply at 90 degrees into the abdomen away from the painful or tender area. Then suddenly release
pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more
—the pressing in or the releasing—and where on the abdomen the pain occurred.
A nurse is performing an admission assessment on a new client. The client reports black tarry stools and
abdominal pain immediately after eating. What condition would the nurse suspect?
A. peptic ulcer
B. indigestion
C. constipation
D. Crohn disease correct answersA. peptic ulcer
Explanation: Peptic ulcer presents with abdominal pain immediately after eating (gastric ulcer) and
possibly black tarry stools if bleeding is occurring. Signs and symptoms of Crohn disease include weight
loss and malnutrition. Indigestion, also referred to as GERD, presents with signs and symptoms of
hyperacidity after eating large meals. Abdominal pain immediately after eating and black tarry stools are
not signs and symptoms of constipation.
A student nurse is performing a focused abdominal assessment of a hospitalized client. The nursing
instructor determines proper assessment technique when the nursing student performs the assessment
in what order? Place the steps in the correct order.
inspection
auscultation
percussion and palpation correct answersinspection, auscultation, percussion, palpation
Explanation:
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