A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?

Ulcerative colitis.

Appendicitis.

Peritonitis.

Diverticulitis.

Answer and Explanation

The Correct Answer is C

Peritonitis. The assessment findings of an absence of bowel sounds and a very rigid abdomen in a client with severe abdominal pain, nausea, and vomiting are indicative of peritonitis. Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. The inflammation can occur due to an infection or other causes, and it can cause abdominal pain, nausea, vomiting, and a rigid abdomen. An absence of bowel sounds is also a characteristic finding of peritonitis.

A is not the correct answer because ulcerative colitis is a chronic inflammatory bowel disease that causes inflammation and ulcers in the colon and rectum.

B is not the correct answer because appendicitis is inflammation of the appendix, which can cause right lower quadrant abdominal pain, nausea, vomiting, and fever.

D is not the correct answer because diverticulitis is inflammation of one or more diverticula, which are small pouches that can form in the colon. It can cause left lower quadrant abdominal pain, fever, diarrhea, or constipation.

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Correct Answer is B

Explanation

Inspection, followed by Auscultation, Percussion, and Palpation. Inspection assesses for abdominal contour, symmetry, any visible masses, scars or other abnormalities. Auscultation assesses bowel sounds, and Percussion assesses for any areas of tenderness, and to determine the presence of fluid, gas or masses. Palpation assesses for any masses, areas of tenderness, organ size or other abnormalities. This is the order that allows the nurse to assess the abdomen systematically and accurately.

A: Palpation comes last because it can stimulate bowel sounds, which can make the nurse miss some of the sounds while auscultating.

C: Auscultation must be done before percussion and palpation to prevent altering bowel sounds.

D: Percussion comes before palpation to avoid altering the underlying structures of the abdomen.

A. Cardiac and respiratory status. B. Circulation, movement, and sensation. C. ROM status. D. Renal and hepatic function.

Correct Answer is B

Explanation

Before and after applying a cast, it is essential to assess the client's circulation, movement, and sensation to ensure there is no damage to the nerves or blood vessels. Assessing cardiac and respiratory status is not as relevant to cast application. ROM status is important but can be assessed by assessing movement and sensation. Renal and hepatic function are not directly related to cast application.

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A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)

Correct Answer is B

Explanation

The nurse is caring for a client who has had a fracture reduction using a cast. Which of the following would be most important for the nurse to assess before and after the cast application?

Correct Answer is B

Explanation

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