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123 Cards in this Set
- Front
- Back
- 3rd side (hint)
Right upper quadrant
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ascending & transverse colon
duodenum gall bladder hepatic flexure of the colon liver pancreas (head) pylorus right adrenal gland right kidney (upper pole) right ureter |
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Right lower quadrant
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appendix
ascending colon cecum right kidney (lower pole) right ovary and tube right ureter right spermatic cord |
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Left upper quadrant
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left adrenal gland
left kidney ( upper pole) left ureter pancreas spleen splenic flexure of colon stomach transverse and descending colon |
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left lower quadrant
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left kidney (lower lobe)
left ovary and tube left ureter left spermatic cord descending and sigmoid colon |
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midline
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bladder
uterus prostate gland |
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outer most layer of the abdominal wall
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external abdominal oblique
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middle layer of the abdominal wall
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internal abdominal oblique
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the inner most layer of the abdominal wall?
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transverse abdominis
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The location of the liver ?
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fills most of the RUQ
composed of 4 lobes extends to the left mid clavicular line extends just below the right coastal margin( where it can be palpated) |
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If palpable the liver an be described as having a ?
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soft consistency
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Where is the pancreas located?
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behind the stomache
deep in the upper abdomen normally not palpable extends from the RUQ to the LUQ |
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The functions of the pancreas?
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accessory organ
and endocrine gland |
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The functions of the liver ?
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accessory digestion organ
metabolic and regulatory functions |
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Largest solid organ?
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Liver
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Where is the nurse most likely to palpate the liver?
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just below the right coastal regions
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Where can the spleen be palpated?
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normally it is not palpable.
TRICK QUESTION. |
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Where is the spleen located?
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above the left kidney, just below the diaphragm at the level of the 9th. 10th. and 11th. ribs
appr. 7 cm. wide |
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Where kidney tenderness is best assessed ?
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at the costovertebral angle
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Functions of the kidneys?
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filtration and elimination of metabolic waste products.
blood pressure control maintenance in water and electrolytes endocrine glands by secreting hormones. |
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Functions of the spleen?
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filter the blood of cellular debris
digest microorganisms return the breakdown products to the liver |
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What is the onset for pain produced by acute pancreatitis?
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sudden onset
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Pancreatic cancer pain begins as ?
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gradual or reacurrent
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If upon auscultation the nurse does not hear bowel sounds or decreased bowel sounds she would then?
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give an M.D. referral; it is an emergency requiring immediate attention
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Absent bowel sounds or diminished bowel sounds are associated with ?
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peritonitis or paralytic ileus.
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High pitched tinkling and rushes of high pitched sounds accompanied by abdominal cramping are associated with ?
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obstruction
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ABNORMAL
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Aspirin, ibuprofen, and steroids can cause what side effects on the stomach?
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may cause gastric bleeding.
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iron supplements can cause?
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constipation
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weight loss and fatigue is associated with ?
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cancer and chronic intestinal disorders.
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gall bladder cancer risks
age? sex? nationality? |
>70 years old
female after menopause native American typhoid carrier obesity |
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what is the first thing a client should do to prepare for an abdominal examination?
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empty bladder
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Where should the clients arms be during the abdominal exam?
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at their side or on their chest.
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purple discoloration at the flanks could indicate?
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bleeding within the abdominal wall from trauma to the kidneys, pancreas, duodenum, or from the pancreatitis
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dark bluish-pink striae is associated with?
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Cushing's syndrome
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deep irregular scars may result from?
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burns
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bluish or purple discoloration around the umbilicus indicates?
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intra-abdominal bleeding
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A deviated umbilicus could be caused by? List five.
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pressure from a mass
enlarged organs hernia fluid scar tissue |
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an everted umbilicus is seen with?
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abdominal distention
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an enlarged everted umbilicus is associated with?
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umbilical hernia
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generalized protuberant abdomen is associated with?
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gas or fluid accumalation
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generalized protuberant abdomen is associated with?
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gas or fluid accumalation
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distention below the umbilicus is associated with?
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full bladder.
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distention of the upper abdomen may be seen with?
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masses of the pancreas or gastric dilation
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the six F's related to abdominal distention.
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fat
fluid fetus flatulence fibroids feces |
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a mass within the abdominal wall is more prominent when?
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when the head is raised
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Normal abdominal respiratory movement may be seen in what clients?
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male
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diminished abdominal respiration or change to thoracic breathing in male clients may reflect?
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peritoneal irritation
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scaphoid and distended protuberant abdomen is what type of finding?
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abnormal
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How would the nurse assess the abdomen for hernia or diastasis recti ?
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have the client raise their head?
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vigorous, wide, exaggerated, abdominal aortic pulsations may be seen is clients with?
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abdominal aortic aneurysm
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to auscultate bruit the nurse would use the ____________ of the stethoscope?
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bell
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to auscultate friction rubs the nurse uses the _____________of the stethoscope?
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diaphragm
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lateral bending of the head is ?
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40 degrees to each side.
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rotation of the head right and left is ?
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70 degrees to each side
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hyperextension of the head is
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45 degree
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flexion of the head is
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55 degree
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kyphosis is a common finding in what age group?
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elderly
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bending forward to touch toes
is what type of movement? |
flexion and its normal is 90 degrees:
75 to 90 is normal with a fattening of the lumbar concavity |
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lateral curvature disappears in what type of scoliosis?
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functional
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unilateral exaggerated thoracic convexity increases in what type of scoliosis?
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structural
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IF assessing a clients ROM by bending side to side where would the nurse be?
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client standing
nurse behind the client stabilizing the pelvis with the nurses hands. |
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lateral bending of the thoracic and lumbar should be how many degrees?
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35 on each side
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hyperextention of the lumbar and thoracic spine?
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30 degrees
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lateral rotation of the thoracic and lumbar spine should be ?
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30 degrees
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Impaired ROM to the thoracic and lumbar back is generally the result of?
List four |
injury to the soft tissue
osteoarthritis ankylosing spondylitis and congenital abnormalities |
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What test should be performed it the client reports lower back pain?
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Lasegue's test.
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Lower back pain that shoots and radiates down one or both legs below the knees may be caused by?
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herniated disc.
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How to perform the Laseques test = straight leg raising
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client lie flat
raise affected leg to the point of pain at point of pain, dorsiflex the foot ABNORMAL FINDING= pain is reproduced. |
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What does the nurse do if she suspects the client has one leg longer than the other?
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measure the leg between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side of the knee= true leg length
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unequal leg length are associated with?
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scoliosis
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equal true leg length but unequal apparent leg lengths are seen with?
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abnormalities in the structure or position of the hips and pelvis
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muscle atrophy is seen with?
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nerve or muscle damage or lack of use.
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flat hollow or less rounded shoulders are seen with ?
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dislocation
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tenderness, swelling, and heat in the shoulders may be noted with ?
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shoulders strains, arthritis, bursitis, or degenerative joint disease.
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ROM of the arms
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forward flexion= arms forward is 180°
extension arms backwards is 50 degrees adduction of the arm is 50 degrees abduction= hand across body and over head is 180 degrees |
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painful and limited abduction ( arms over head) of the arms accompanied by muscle weakness and atropy is seen with ?
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rotator cuff tear.
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Client has sharp catches of pain when bringing hands over head is associated with?
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rotator cuff injury
rotator cuff tendinitis |
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chronic pain and severe limitation of all shoulder motions are seen with ?
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calcified tendinitis
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Measurements of the legs are equal if they are?
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within 1 cm
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deep palpation
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push down 5-8 cm.
assessing location, size , consistency, mobility of an organ |
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If the liver is 1-2 cm. below the right coastal margin, this would be considered?
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enlarged
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How wide is the normal spleen?
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less than 7 cm wide.
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If a cleint state he is constipated, what should the nurse do?
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Ask what they mean by "constipated"
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to hear bowel sounds the nurse uses diaphragm or bell?
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diaphragm
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Hypoactive bowel sounds defined as sounds heard how often?
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common after surgery
fewer than 5 sounds in one minute |
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Hyperactive bowel sounds are defined as sounds heard....?
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greater than 30 sounds a minute
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Absent bowel sounds must be assessed for how many minutes before they can be documented as "absent"
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5 full minutes
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When is hyperresonance is heard ?
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over gaseous distention
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hyperactive bowel sounds are commonly heard in a client with ?
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diarrhea
gastroenteritis early bowel obstruction |
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hypoactive bowel sounds are common is clients ?
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returning from surgery
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If a client has a mass below the abdominal wall will the mass be visible when the client raises their head?
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No
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a bruit?
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low pitched murmurlike sounds
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Characteristic sound and organ span of splenomegaly are?
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dullness greater than 7 cm.
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To rule out splenomegaly what else should be assessed?
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a full stomach
or feces in the colon |
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to palpate the urinary bladder to nurse would ?
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begin at the pubic symphysis and move upward and outward to estimate bladder borders.
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to further assess for ascites after performing the fluid wave test, what other test would need to be performed?
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an ultrasound
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characteristics of fat
What sound is percussed? abnormal |
uniformly protuberant
wall is thick tympany is the sound percussed umbilicus is sunken |
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characteristics of feces within the abdomen.
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localized distention
dullness is percussed |
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Characteristics of fibroid and other masses
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generalized distention in lower abdomen
mass displaces bowel dullness is percussed with tympany at the periphery umbilicus may be everted |
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Characteristics of flatus
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generalized protuberance or localized protuberance
tympany is percussed over the area |
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characteristics of ascites fluid ?
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generalized protuberance
bulging flanks everted umbilicus percussion reveals dullness over fluid. percussion reveals tympany over intestines. |
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What is an umbilicus hernia.
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bowel protruding through a weakness in the umbilical ring
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epigastric hernia
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bowel protrudes through a weakness in the linea alba. small bulge appears midline between the xiphoid process and the umbilicus. usually discovered only with palpation.
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diastasis recti
abnormal but not significant |
not a significate finding
bowel protrudes through a seperation between the two rectus abdominis muscles. appears at the midline ridge. visible when the client raises their head or coughs. |
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characteristics of an incisional hernia
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appears as a bulge at the surgical site
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an enlarged, firm, hard, nodular liver indicates?
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cancer
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an enlarged, non-tender liver suggest ?
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cirrhosis
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an enlarged tender liver suggest?
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CHF
acute hepatitis or abscess |
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Where could the nurse expect bowel sounds to be more active?
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over the iliocecal valve in the RLQ
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Characteristics of an enlarged gallbladder.
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extremely tender
postive Murphy's sign |
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during palpation the normal abdomen will be tender in what locations?
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over xiphoid process,liver,aorta, lower pole of the kidney, gas filled cecum, sigmoid colon, ovaries.
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venous hum is associated with?
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cirrhosis of the liver
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the bell is used to hear
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venous hums
bruits |
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diaphram of the scope is used to hear?
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friction rubs
bowel sounds |
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friction rubs heard over the lower right coastal area is associated with?
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hepatic abscess
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friction rubs heard at the left axially line in the lower left coastal area is associated with?
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splenic infraction, abscess, infection, or tumor.
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abnormal dullness is heard
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over ascites,distended bladder, large masses,
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tympany or hyperresonance is heard
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over a gaseous distended abdomen
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normal dullness is heard
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over the liver and spleen
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a normal abdomen feels?
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soft, mild tenderness, no masses,
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if the liver is felt it should feel?
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firm, smooth, and even
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if the liver is felt it should feel?
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firm, smooth, and even
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An enlarged spleen could be the result of ? List four.
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trauma, mononucleosis, chronic blood disorders, or cancer
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If the spenic notch is felt, this would indicate?
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splenic enlargment
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