NUR 210 final exam Questions With Correct Answers.

While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating what complication? - Answer-infection Which change in auscultation of bowel sounds should the nurse recognize as most diagnostic of an intestinal obstruction? - Answer-An increase in the pitch The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment? - Answer-Ask the client to breathe slowly and deeply Linda is a 29-year-old who had excruciating pain that started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely given this presentation? - Answer-ureteral stone The nurse provides teaching to a client with gastroesophageal reflux disease (GERD). Which client statement indicates that teaching has been effective? - Answer-"I should avoid lifting heavy objects." A client expresses pain when the left costovertebral angle is palpated. What should the nurse suspect is occurring with this client? Select all that apply. - Answer-Renal calculi Kidney infection Hydronephrosis A nurse suspects intra-abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion? - Answer-Cullen's sign A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. What bowel sound would the nurse expect to assess in this client? - Answer-absent The client with a acute appendicitis has been ordered a barium enema. What should the nurse do first? - Answer-Question the order as a barium enema is contraindicated in acute appendicitisA nurse observes the abdomen of a client and notices it to be distended below the umbilicus. The nurse recognizes that this can be caused by which of these conditions? Select all that apply. - Answer-Ovarian tumor Impacted colon Uterine enlargement Full bladder A 46-year-old former salesman presents to the ER complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. Examination shows a man appearing older than his stated age. His skin has a yellowish tint and he is thin with a prominent abdomen. Multiple "spider angiomas" are at the base of his neck. Otherwise his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is smal - Answer-Esophageal varices A client complains of abdominal pain that is worsened when he lies on his back. The nurse should suspect which of the following as the underlying cause? - Answer-Gastroesophageal reflux The nurse has the client participate in the assessment technique shown. For which health problem is the nurse assessing in this client? - Answer-Ascites A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation? - Answer-Right side-lying The client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for? - Answer-Acute pancreatitis A nurse performs light palpation of the abdomen and feels a prominent, non-tender, pulsating mass above the umbilicus that measures approximately six (6) centimeters. What is an appropriate action by the nurse? - Answer-Stop the palpation and notify the health care providerDuring the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign? - Answer-Murphy's sign When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding? - Answer-Bowel sounds normal A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause? - Answer-Gastric ulcer