1.
The sigmoid colon is located in this area of the abdomen: the
Correct Answer
B. Left lower quadrant
Explanation
The sigmoid colon is located in the left lower quadrant of the abdomen. This is the area of the abdomen that is positioned towards the left side and lower part of the abdominal region. The sigmoid colon is the S-shaped part of the large intestine that connects the descending colon to the rectum. Its location in the left lower quadrant is consistent with its anatomical position in the abdomen.
2.
The pancreas of an adult is located
Correct Answer
C. Deep in the upper adbomen and is not normally palpable
Explanation
The correct answer is "deep in the upper abdomen and is not normally palpable." The pancreas is located deep within the upper abdomen, behind the stomach and in front of the spine. It is not easily felt or palpated during a physical examination. This positioning allows the pancreas to carry out its functions related to digestion and hormone production effectively.
3.
The primary function of the gallbladder is to
Correct Answer
A. Store and excrete bile
Explanation
The gallbladder's primary function is to store and excrete bile. Bile is produced by the liver and helps in the digestion and absorption of fats. The gallbladder stores bile and releases it into the small intestine when needed, particularly after a meal that contains fat. This allows for the efficient breakdown and absorption of dietary fats. Therefore, the correct answer is "store and excrete bile."
4.
The colon originates in this abdominal area: the
Correct Answer
A. Right lower quadrant
Explanation
The colon, a part of the large intestine, is located in the abdominal area. Specifically, it is situated in the right lower quadrant of the abdomen. This area is located on the right side of the body, below the belly button and to the right of the midline. The colon extends from the cecum, which is in the right lower quadrant, to the sigmoid colon, which is in the left lower quadrant. Therefore, the correct answer is the right lower quadrant.
5.
To percuss the liver of an adult, where should the nurse begin the assessment?
Correct Answer
A. Right upper quadrant
Explanation
The nurse should begin the assessment to percuss the liver in the right upper quadrant. The liver is located in the upper right side of the abdomen, just below the diaphragm. Percussion is a technique used to tap on the body's surface to produce sounds that can help assess the size, density, and location of organs. Starting the assessment in the right upper quadrant allows the nurse to accurately locate and assess the liver.
6.
To palpate tenderness of an adult's appendix, where should you begin?
Correct Answer
C. Right lower quadrant
Explanation
To palpate tenderness of an adult's appendix, you should begin in the right lower quadrant. The appendix is located in the lower right area of the abdomen, so palpating tenderness in this region can help identify any potential issues with the appendix. The other quadrants are not typically associated with tenderness of the appendix.
7.
To palpate the spleen, where should you begin the assessment?
Correct Answer
C. Left upper quadrant
Explanation
To palpate the spleen, you should begin the assessment in the left upper quadrant. The spleen is located in the upper left side of the abdomen, just below the rib cage. Palpating the left upper quadrant allows for proper identification and assessment of the spleen. The right upper and lower quadrants are not relevant to palpating the spleen.
8.
If assessing a client for kidney tenderness, where would you begin?
Correct Answer
D. Costovertebral angle
Explanation
When assessing a client for kidney tenderness, you would begin by examining the costovertebral angle. This is the area where the ribs meet the spine on the back, just below the lower edge of the ribcage. The kidneys are located in this region, and tenderness in the costovertebral angle may indicate kidney problems or inflammation. Therefore, starting the assessment by checking this area is crucial in identifying any potential issues related to the kidneys.
9.
A client has experienced hematemesis, what is this?
Correct Answer
B. Blood in the vomit (emesis)
Explanation
Hematemesis refers to the presence of blood in the vomit. It is a medical condition characterized by the vomiting of blood, which can range from small traces to large amounts. This condition can be caused by various factors such as gastrointestinal bleeding, stomach ulcers, liver disease, or trauma to the digestive tract. It is important to seek medical attention if hematemesis occurs as it may indicate a serious underlying health issue.
10.
What is hematemesis evidence of?
Correct Answer
A. Stomach ulcers
Explanation
Hematemesis, which refers to the vomiting of blood, is evidence of stomach ulcers. Stomach ulcers are open sores that develop on the lining of the stomach, often caused by the erosion of the protective mucous layer. When these ulcers bleed, it can result in the presence of blood in the vomit, known as hematemesis. This symptom is a clear indication of the presence of stomach ulcers and should be evaluated and treated by a healthcare professional.
11.
The nurse assessing an older client who has lost 5 ounds since her last visit 1 year ao. The client tells the nurse her husband died 2 months ago. The nurse should assess for
Correct Answer
C. Appetite changes
Explanation
The correct answer is appetite changes. The nurse should assess for appetite changes because the client has experienced weight loss since her last visit and recently experienced a significant life event, the death of her husband. These factors could contribute to changes in appetite, which could be indicative of an underlying health issue. The nurse should further assess the client's eating habits, food preferences, and any other symptoms related to appetite changes to determine the appropriate course of action.
12.
The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first
Correct Answer
D. Inspect the abdominal area
Explanation
The nurse should first inspect the abdominal area. This is important to assess for any visible signs of infection, such as redness, swelling, or drainage, as well as any abnormalities or changes in the appearance of the abdomen. Palpating the incision site, auscultating for bowel sounds, and percussing for tympany can be done after inspecting the abdomen.
13.
The nurse is planning to assess the abdomen of an adult male. What should be done first?
Correct Answer
A. Ask client to empty bladder
Explanation
Before assessing the abdomen of an adult male, the nurse should ask the client to empty their bladder. This is important because a full bladder can interfere with the accuracy of abdominal assessment findings. By emptying the bladder, the nurse ensures that there is no distention or discomfort that may affect the assessment process.
14.
If a client's umbilicus is enlarged and to the left - what is this indicative of?
Correct Answer
A. Umbilical hernia
Explanation
If a client's umbilicus is enlarged and to the left, it is indicative of an umbilical hernia. An umbilical hernia occurs when a portion of the intestine or fatty tissue bulges through the abdominal wall near the umbilicus. This can cause the umbilicus to appear enlarged and displaced to one side. Other conditions such as ascites, intraabdominal bleeding, or pancreatitis would not specifically cause the umbilicus to be enlarged and to the left.
15.
Decreased abdominal respiration, the client should be further assessed for
Correct Answer
D. Peritoneal irritation
Explanation
The client's decreased abdominal respiration suggests that there may be an issue with the peritoneum, the membrane lining the abdominal cavity. Peritoneal irritation can occur due to various reasons such as infection, inflammation, or injury. It is important to further assess the client to determine the underlying cause of the peritoneal irritation and provide appropriate treatment.