NUR 325 Health Assessment Exam 5
with 156 verified solutions 100% Rated.
NUR 325 Health Assessment Exam 5
with 156 verified solutions 100% Rated.
Location of internal organs - ANSWER--Liver on the right
-Spleen on the left
-Right kidney lower than left because of liver
-Kidneys under 12th (lowest posterior) rib/ Costovertebral angle
Costovertebral angle - ANSWER-Kidneys under 12th (lowest posterior) rib
Right Upper Quadrant (RUQ) - ANSWER-Liver
Gallbladder
Duodenum
Head of pancreas
Right kidney and adrenal
Hepatic flexure of colon
Part of ascending and transverse colon
Left Upper Quadrant (LUQ) - ANSWER-Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney and adrenal
Splenic flexure of colon
Part of transverse and descending colon
Right Lower Quadrant (RLQ) - ANSWER-Cecum
Appendix
Right ovary and tube
Right ureter
Right spermatic cord
Left Lower Quadrant (LLQ) - ANSWER-Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
Midline - ANSWER-Aorta
Uterus (if enlarged)
Bladder (if distended)
,NUR 325 Health Assessment Exam 5
with 156 verified solutions 100% Rated.
history of a patient who is having abdominal complaints - ANSWER--Appetite
-Dysphagia
-Food Intolerance
-Abdominal Pain
-Nausea and Vomiting
-Bowel habits
-Past GI Issues
-Operations
-Abdominal studies (x-ray, colonoscopy, EGD)
-Medications
-Alcohol
-Smoking
-Nutritional Assessment (24 hour diet recall)
-Obesity
Subjective Data - Infants and Children - ANSWER-• Breastfed or Bottle fed?
• Which table foods have been introduced?
• How often does your child eat? Scheduled?
Snacks?
• Does child eat nonfoods? Grass/dirt/paint chips?
• Constipation? Abdominal Pain?
• Overweight? Diet? Activity?
•Pica
Subjective Data - Adolescents - ANSWER-• Regular meal? Breakfast? Snacks?
• Calories? Exercise?
• Screen for extreme weight loss
• How does adolescent view body?
• What do parents or friends say about eating habits?
•Anorexia Nervosa
Subjective Data - Elderly - ANSWER-• How does person get groceries? Prepare meals?
• Eat alone? With others?
• Trouble swallowing foods? What do you do after eating?
• How often does person have a bowel movement? Laxatives?
• Medications? Any GI side effects?
Sequence of Abdominal Exam - ANSWER-• Inspection
• Auscultation
• Percussion
• Palpation
*Percussion and Palpation can increase peristalsis and give a false interpretation of
bowel sounds
, NUR 325 Health Assessment Exam 5
with 156 verified solutions 100% Rated.
prepare and position the patient for an abdominal exam - ANSWER-•The person should
have emptied the bladder, saving a urine specimen if needed.
•Place the person supine, with the head on a pillow, the knees bent or on pillow, and the
arms at the sides or across the chest. (NOTE: Discourage the person from placing his
or her arms over the head because this tenses abdominal musculature.)
Black stools - ANSWER-May be tarry due to occult blood (melena) from upper GI
bleeding or nontarry from iron medications.
Red blood - ANSWER-in stools occurs with lower GI bleeding or localized bleeding
around the anus
Gray stools - ANSWER-occur with hepatitis.
Flat - ANSWER-
Scaphoid - ANSWER-sunken abdominal wall
Rounded - ANSWER-slightly protruding abdominal wall
Protuberant - ANSWER-greatly protruding abdominal wall
Normoactive bowel sounds - ANSWER-high-pitched, gurgling and cascading sounds
that occur irregularly 5-30 times per minute
Hyperactive bowel sounds - ANSWER-loud, high-pitched, rushing, tinkling sounds due
to increased motility
Hypoactive bowel sounds - ANSWER-Occur due to surgery or with inflammation of the
peritoneum - "silent abdomen" can only be determined only if assessed for 5 minutes
Assessing bowel sounds - ANSWER-• Remember that percussion and palpation can
increase peristalsis and falsely increase them
• Use the diaphragm of stethoscope because they are high pitched (hold lightly to skin -
pressing too hard may stimulate them)
• Begin exam in the RLQ due to ileocecal valve and they are normally present
•Move in a clock wise fashion starting in the RLQ
Auscultation of vascular sounds - ANSWER-•Use the bell of the stethoscope for
vascular sounds
•Using firmer pressure, check over the aorta, renal and iliac arteries (esp. in persons
with hypertension) usually no sounds noted
•Listen for systolic bruits
•Aorta
with 156 verified solutions 100% Rated.
NUR 325 Health Assessment Exam 5
with 156 verified solutions 100% Rated.
Location of internal organs - ANSWER--Liver on the right
-Spleen on the left
-Right kidney lower than left because of liver
-Kidneys under 12th (lowest posterior) rib/ Costovertebral angle
Costovertebral angle - ANSWER-Kidneys under 12th (lowest posterior) rib
Right Upper Quadrant (RUQ) - ANSWER-Liver
Gallbladder
Duodenum
Head of pancreas
Right kidney and adrenal
Hepatic flexure of colon
Part of ascending and transverse colon
Left Upper Quadrant (LUQ) - ANSWER-Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney and adrenal
Splenic flexure of colon
Part of transverse and descending colon
Right Lower Quadrant (RLQ) - ANSWER-Cecum
Appendix
Right ovary and tube
Right ureter
Right spermatic cord
Left Lower Quadrant (LLQ) - ANSWER-Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
Midline - ANSWER-Aorta
Uterus (if enlarged)
Bladder (if distended)
,NUR 325 Health Assessment Exam 5
with 156 verified solutions 100% Rated.
history of a patient who is having abdominal complaints - ANSWER--Appetite
-Dysphagia
-Food Intolerance
-Abdominal Pain
-Nausea and Vomiting
-Bowel habits
-Past GI Issues
-Operations
-Abdominal studies (x-ray, colonoscopy, EGD)
-Medications
-Alcohol
-Smoking
-Nutritional Assessment (24 hour diet recall)
-Obesity
Subjective Data - Infants and Children - ANSWER-• Breastfed or Bottle fed?
• Which table foods have been introduced?
• How often does your child eat? Scheduled?
Snacks?
• Does child eat nonfoods? Grass/dirt/paint chips?
• Constipation? Abdominal Pain?
• Overweight? Diet? Activity?
•Pica
Subjective Data - Adolescents - ANSWER-• Regular meal? Breakfast? Snacks?
• Calories? Exercise?
• Screen for extreme weight loss
• How does adolescent view body?
• What do parents or friends say about eating habits?
•Anorexia Nervosa
Subjective Data - Elderly - ANSWER-• How does person get groceries? Prepare meals?
• Eat alone? With others?
• Trouble swallowing foods? What do you do after eating?
• How often does person have a bowel movement? Laxatives?
• Medications? Any GI side effects?
Sequence of Abdominal Exam - ANSWER-• Inspection
• Auscultation
• Percussion
• Palpation
*Percussion and Palpation can increase peristalsis and give a false interpretation of
bowel sounds
, NUR 325 Health Assessment Exam 5
with 156 verified solutions 100% Rated.
prepare and position the patient for an abdominal exam - ANSWER-•The person should
have emptied the bladder, saving a urine specimen if needed.
•Place the person supine, with the head on a pillow, the knees bent or on pillow, and the
arms at the sides or across the chest. (NOTE: Discourage the person from placing his
or her arms over the head because this tenses abdominal musculature.)
Black stools - ANSWER-May be tarry due to occult blood (melena) from upper GI
bleeding or nontarry from iron medications.
Red blood - ANSWER-in stools occurs with lower GI bleeding or localized bleeding
around the anus
Gray stools - ANSWER-occur with hepatitis.
Flat - ANSWER-
Scaphoid - ANSWER-sunken abdominal wall
Rounded - ANSWER-slightly protruding abdominal wall
Protuberant - ANSWER-greatly protruding abdominal wall
Normoactive bowel sounds - ANSWER-high-pitched, gurgling and cascading sounds
that occur irregularly 5-30 times per minute
Hyperactive bowel sounds - ANSWER-loud, high-pitched, rushing, tinkling sounds due
to increased motility
Hypoactive bowel sounds - ANSWER-Occur due to surgery or with inflammation of the
peritoneum - "silent abdomen" can only be determined only if assessed for 5 minutes
Assessing bowel sounds - ANSWER-• Remember that percussion and palpation can
increase peristalsis and falsely increase them
• Use the diaphragm of stethoscope because they are high pitched (hold lightly to skin -
pressing too hard may stimulate them)
• Begin exam in the RLQ due to ileocecal valve and they are normally present
•Move in a clock wise fashion starting in the RLQ
Auscultation of vascular sounds - ANSWER-•Use the bell of the stethoscope for
vascular sounds
•Using firmer pressure, check over the aorta, renal and iliac arteries (esp. in persons
with hypertension) usually no sounds noted
•Listen for systolic bruits
•Aorta
