Preview Extract
Chapter 44
1. The nurse is caring for an adolescent client who has experienced trauma to his spleen that
requires its removal. When discussing the proposed surgery with the client’s parents, the
nurse shares with them that the spleen:
Select all that apply.
1. Is found in the left upper abdominal quadrant.
2. Destroys aged red blood cells.
3. Acts as a blood filtration system.
4. Has a minimal vascular system.
5. Is involved in the return of bile to the liver.
Answer: 1. Is found in the left upper abdominal quadrant.
2. Destroys aged red blood cells.
3. Acts as a blood filtration system.
Rationale:
Is found in the left upper abdominal quadrant. The spleen can be found in the left upper
quadrant of the abdomen. Destroys aged red blood cells. A primary purpose of the spleen is to
destroy aged red blood cells. Acts as a blood filtration system. A primary purpose of the
spleen is to filter blood. Has a minimal vascular system. Because of its extensive vascular
nature, this is an organ that, when injured in a trauma to the abdomen, can be life threatening.
Is involved in the return of bile to the liver. A primary purpose of the spleen is to filter blood,
destroy aged red blood cells, and return their by-products, particularly bilirubin, to the liver.
2. When a older adult client states, “My mouth is always dry,” the nurse realizes that this
client may be at a risk for developing an oral infection primarily because:
1. A dry mouth is lacking in bacteria-fighting immunoglobulin A.
2. Poorly chewed food will remain in the mouth, supporting bacterial growth.
3. A lack of salivary gland lubrication makes chewing the food difficult, resulting in gum
trauma.
4. The normal aging process reduces the antibacterial properties of saliva.
Answer: A dry mouth is lacking in bacteria-fighting immunoglobulin A.
Rationale:
Saliva contains large amounts of ions, such as immunoglobulin A, a vital component for
destroying oral bacteria. A lack of saliva increases the risk of infection from oral pathogens.
While poorly chewed food that remains in the oral cavity does support bacterial growth and a
lack of oral lubrication may make chewing food more difficult, they are not the primary risk
factors in this scenario. Normal aging does not appear to have an affect on the antibacterial
properties of saliva.
3. The client reports feeling pain in the right lower quadrant. The nurse shows an
understanding of the anatomical location of organs in the abdomen by asking the client:
1. “Can you tell me about your voiding habits?”
2. “Do you get clammy when you miss a meal?”
3. “When you eat, do you experience any nausea?”
4. “Do you have any problems eating fatty foods?”
Answer: “Can you tell me about your voiding habits?”
Rationale:
The right lower quadrant contains the kidneys. Discussing voiding is indicated. The other
statements relate to the stomach, gallbladder, and pancreas; the stomach is located in the left
upper quadrant while the gallbladder and the pancreas are located in the right upper quadrant.
4. The nurse is preparing to assess a client who reports abdominal pain of 6 on a scale of 0 to
10. In order to best facilitate the abdominal assessment, the nurse:
1. Assists the client into the knees-bent supine position.
2. First medicates the client for the pain.
3. Encourages the client to take slow, deep breaths.
4. Palpates the client’s abdomen last.
Answer: Assists the client into the knees-bent supine position.
Rationale:
The nurse should work with the patient in establishing a comfortable position for the patient;
this will make the examination more productive for both of them and allow for the client to
be cooperative during the procedure. The knees-bent supine position is often more
comfortable than lying flat on the back. Medication for pain may not be prescribed if the
cause of the pain is still undetermined. Slow, deep breathing may help the client manage the
pain, but it will not have the same impact on the assessment as comfortable positioning.
Palpation of the abdomen may cause pain and should be performed last, but the client is
already experiencing pain, so palpation will not have as much impact on the assessment as
will comfortable positioning.
5. The nurse is initiating a history and physical assessment on a client who reports
intermittent right-sided abdomen pain, especially after eating fatty foods. The nurse
recognizes that the history interview:
Select all that apply:
1. Establishes the nurse−client relationship.
2. Encourages the client to express his or her concerns.
3. Includes documentation of the client’s own words.
4. Should be directed toward ruling out a gallbladder problem.
5. Should be nurse-driven via direct questioning.
Answer: 1. Establishes the nurse−client relationship.
2. Encourages the client to express his or her concerns.
3. Includes documentation of the client’s own words.
Rationale:
Establishes the nurse−client relationship. Taking a history is a very important encounter with
a patient. This is a time when a relationship with a patient is started. Encourages the client to
express his or her concerns. It is important to allow the patient to express concerns and
explain the problem in his or her own words during the history interview. Includes
documentation of the client’s own words. Direct client quotes should be documented as a part
of the interview process. Should be directed toward ruling out a gallbladder problem. The
nurse should keep an open mind, because sometimes information that is initially thought of as
trivial can be the answer to the problem. Should be nurse-driven via direct questioning. It is
important to allow the patient to direct the interview by expressing concerns and explaining
the problem in his or her own words during the history interview. Interruptions should be kept
to a minimum, but clarifying questions should be asked.
6. A client is reporting intermittent pain in the left upper abdomen. In order to best assess the
characteristics of the pain, the nurse asks the client:
Select all that apply.
1. “Can you do anything that makes the pain go away?”
2. “Does anything make the pain worse?”
3. “When did you first notice the pain?”
4. “Can you describe the pain for me?”
5. “What do you think is causing the pain?”
Answer: 1. “Can you do anything that makes the pain go away?”
2. “Does anything make the pain worse?”
3. “When did you first notice the pain?”
4. “Can you describe the pain for me?”
Rationale:
“Can you do anything that makes the pain go away?” Actions that affect the pain (increase,
decrease, or eliminate) are important to the interview. “Does anything make the pain worse?”
Actions that affect the pain (increase, decrease, or eliminate) are important to the interview.
“When did you first notice the pain?” An interview regarding pain characteristics should
include questions directed toward the onset and duration of the pain. “Can you describe the
pain for me?” An interview regarding pain characteristics should include questions directed
toward a description of how it feels. “What do you think is causing the pain?” While asking
the client’s opinion as to the cause of the pain is appropriate, it does not contribute data to the
understanding of the characteristics of the pain itself.
7. When assessing a client’s abdomen, the nurse recognizes the importance of reserving
palpation as the last technique. The rationale for this practice is that:
1. The pressure it causes can interfere with hearing bowel sounds.
2. The technique is likely to increase the client’s level of anxiety.
3. Most clients do not like being touched.
4. Early palpation may result in rebound pain.
Answer: The pressure it causes can interfere with hearing bowel sounds.
Rationale:
When assessing the abdomen, use palpation last because pressure on the abdominal wall and
contents may interfere with bowel sounds and cause pain. Palpation itself does not generally
contribute to a client’s anxiety. The technique does not cause rebound pain, but can cause
general pain in a client’s abdomen. While some clients may be uncomfortable with being
touched, that is not the reason for delaying the technique until last.
8. The nurse is percussing a client’s kidneys as a part of the physical assessment. Which of
the following nursing actions displays a need for further instruction regarding performing this
assessment technique?
1. Gently strikes the client with the palmar surface of the hand
2. Asks the client to sit on the side of the examination table
3. Focuses the examination at the site of the client’s costal vertebral angles
4. Applies the technique to either side of the spine between the last rib and the lumbar
vertebrae
Answer: Gently strikes the client with the palmar surface of the hand
Rationale:
The nurse should make a fist and gently strike the patient with the ulnar surface of the fist in
the costal vertebral angle that is formed on either side of the vertebral column between the
last rib and the lumbar vertebrae. In order to percuss the kidney, the patient must be lying on
one side or be in a sitting position.
9. When percussing a client’s abdomen in order to gather assessment data, the nurse must rely
most heavily on the ability to:
1. Differentiate between the various elicited sounds.
2. Observe subtle variation in the contour of the abdomen.
3. Supplement the technique with fine finger dexterity.
4. Locate the margins of the various abdominal organs.
Answer: Differentiate between the various elicited sounds.
Rationale:
Percussing the abdomen will elicit different sounds. The nurse should be able to hear the
difference between the sounds. While observation, locating organs, and finger dexterity have
a role to play in the abdominal assessment, they do not have as much of an impact on
percussion as the ability to hear the difference between normal and abnormal sounds resulting
from the technique.
10. An abdominal assessment is being performed on an older adult client. When the client is
turned on the side, a sound of dullness is heard with percussion. The nurse interprets this as
data consistent with:
1. Ascites.
2. Normal data.
3. Bowel obstruction.
4. Hepatomegaly.
Answer: Ascites.
Rationale:
The client is demonstrating the presence of ascites. The dullness is present with position
changes. Percussion of a side-lying client is not used to assess for a bowel obstruction or
hepatomegaly. This is not a normal finding.
11. It is thought that a client may be experiencing pancreatitis. The nurse exhibits
understanding of the assessment process for this pathology by:
1. Placing his or her hand on the lateral surface of the client’s flexed right thigh and asking
the client to push against the applied resistance.
2. Anticipating that the client’s health care provider will order a barium enema.
3. Inquiring with radiology when an endoscopy can be scheduled for the client.
4. After having the client both bend the right knee and flex the right hip, he or she flexes the
thigh to a right angle and externally and internally rotates the leg.
Answer: Placing his or her hand on the lateral surface of the client’s flexed right thigh and
asking the client to push against the applied resistance.
Rationale:
This option describes the iliopsoas sign test. When this test is positive (produces pain), it
indicates an inflammation of the iliopsoas muscle group. Clinically, the iliopsoas has relations
to the kidneys, ureters, cecum, appendix, sigmoid colon, pancreas, lumbar lymph nodes, and
nerves of the posterior abdominal wall. When there is intra-abdominal inflammation or
disease of any of theses structures, movement of the iliopsoas causes pain. Barium enema
would enhance intraluminal processes such as colon cancer or diverticular disease.
Endoscopy allows the clinician to visualize the intraluminal space of the upper GI tract. The
obturator sign (painful external and internal rotation of a flexed hip and thigh) is positive in
patients with inflammation along the obturator internus muscle. Positive tests can be related
to appendicitis, diverticulitis, and pelvic inflammatory disease.
12. The nurse assesses for a positive Murphy’s sign in a client suspected of experiencing:
1. Cholecysititis.
2. Diverticulitis.
3. Renal calculi.
4. Urinary retention.
Answer: Cholecysititis.
Rationale:
Murphy’s sign is positive when a person has inflammation of the gallbladder, as seen in
cholecystitis. The remaining options are not assessed by either a positive or negative
Murphy’s sign.
13. When the nurse is documenting data regarding a client’s complaint of abdominal pain, the
following data is included:
Select all that apply.
1. Pain began 24 hours ago.
2. Walking exacerbates the pain.
3. Belching has lessened the pain.
4. Pain described as sharp and stabbing.
5. Client fears losing job if pain causes another absence.
Answer: 1. Pain began 24 hours ago.
2. Walking exacerbates the pain.
3. Belching has lessened the pain.
4. Pain described as sharp and stabbing.
Rationale:
Pain began 24 hours ago. Duration of the problem helps define the chief complaint. Walking
exacerbates the pain. Exacerbation or diminishment of symptoms helps define the chief
complaint. Belching has lessened the pain. Exacerbation or diminishment of symptoms helps
define the chief complaint. Pain described as sharp and stabbing. A description of the problem
(what is wrong) helps define the chief complaint. Client fears losing job if pain causes
another absence. While the client is expressing a fear, it does not relate to the cause of the
pain itself but rather a possible outcome of the pain.
14. The nurse recognizes that a client diagnosed with poorly controlled type 2 diabetes is at
risk for developing the gastrointestinal complication of:
1. Gastroparesis.
2. Gastric reflex disease.
3. Peptic ulcer.
4. Paralytic ileus.
Answer: Gastroparesis.
Rationale:
A person whose diabetes is poorly controlled may develop gastroparesis, a slowing in
emptying of the stomach due to the diabetes. The remaining options do not appear to have a
direct connection to diabetes.
15. The nurse includes the following data when documenting a client’s biographic and
demographic information:
Select all that apply.
1. Gender.
2. Age.
3. Educational background.
4. Urban, rural, or suburban dweller.
5. Daily alcohol consumption.
Answer:
1. Gender.
2. Age.
3. Educational background.
4. Urban, rural, or suburban dweller.
Rationale:
Gender. Biographical data should include gender. Age. Biographical data should include age.
Educational background. Biographical data should include educational background. Urban,
rural, or suburban dweller. Demographic data such as whether the client lives in an urban,
rural or suburban setting is appropriate. Daily alcohol consumption. Alcohol consumption
would be a part of the medical history.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
