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An advanced practice nurse is assessing the size and density of a patient's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented?
- A. Percussion
- B. Auscultation
- C. Inspection
- D. Rectal examination
Correct Answer: A
Rationale: Percussion is used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, or solid masses. Percussion is used either independently or concurrently with palpation because it can validate palpation findings.
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Probably the most widely used in-office or at-home occult blood test is the Hemoccult II. The patient has come to the clinic because he thinks there is blood in his stool. When you reviewed his medications, you noted he is on antihypertensive drugs and NSAIDs for early arthritic pain. You are sending the patient home with the supplies necessary to perform 2 hemoccult tests on his stool and mail the samples back to the clinic. What instruction would you give this patient?
- A. Take all your medications as usual.
- B. Take all your medications except the antihypertensive medications.
- C. Don't eat highly acidic foods 72 hours before you start the test.
- D. Avoid vitamin C for 72 hours before you start the test.
Correct Answer: D
Rationale: Red meats, aspirin, nonsteroidal anti-inflammatory drugs, turnips, and horseradish should be avoided for 72 hours prior to the study, because they may cause a false-positive result. Also, ingestion of vitamin C from supplements or foods can cause a false-negative result. Acidic foods do not need to be avoided.
A nurse is assessing the abdomen of a patient just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the patient's abdomen. How should the nurse best interpret this assessment finding?
- A. Abdominal lesions are usually due to age-related skin changes.
- B. Integumentary diseases often cause GI disorders.
- C. GI diseases often produce skin changes.
- D. The patient needs to be assessed for self-harm.
Correct Answer: C
Rationale: Abdominal lesions are of particular importance, because GI diseases often produce skin changes. Skin problems do not normally cause GI disorders. Age-related skin changes do not have a pronounced effect on the skin of the abdomen when compared to other skin surfaces. Self-harm is a less likely explanation for skin lesions on the abdomen.
A clinic patient has described recent dark-colored stools; the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the patient's current health status would contraindicate FOBT?
- A. Gastroesophageal reflux disease (GERD)
- B. Peptic ulcers
- C. Hemorrhoids
- D. Recurrent nausea and vomiting
Correct Answer: C
Rationale: FOBT should not be performed when there is hemorrhoidal bleeding. GERD, peptic ulcers and nausea and vomiting do not contraindicate the use of FOBT as a diagnostic tool.
The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test?
- A. In a knee-chest position (lithotomy position)
- B. Lying prone with legs drawn toward the chest
- C. Lying on the left side with legs drawn toward the chest
- D. In a prone position with two pillows elevating the buttocks
Correct Answer: C
Rationale: For best visualization, colonoscopy is performed while the patient is lying on the left side with the legs drawn up toward the chest. A knee-chest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization.
The nurse is preparing to perform a patient's abdominal assessment. What examination sequence should the nurse follow?
- A. Inspection, auscultation, percussion, and palpation
- B. Inspection, palpation, auscultation, and percussion
- C. Inspection, percussion, palpation, and auscultation
- D. Inspection, palpation, percussion, and auscultation
Correct Answer: A
Rationale: When performing a focused assessment of the patient's abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds. The traditional sequence for all other focused assessments is inspection, palpation, percussion, and auscultation.