The nurse is preparing to percuss the abdomen of a patient. Which ...

[rl]

The nurse is preparing to percuss the abdomen of a patient. Which information indicates that the nurse might need assistance with this assessment?
 
  1. The nurse plans to use a systematic approach for the assessment.
  2. The nurse anticipates hearing tympany over stool-filled intestines.
  3. The nurse anticipates hearing dullness over the liver.
  4. The nurse plans to percuss the spleen, liver, and kidneys.

Question 2

The nurse is preparing to assess a patient with a suspected abdominal mass. Which techniques should the nurse use for this assessment?
 
  Select all that apply.
  1. Shine a light source across the abdomen.
  2. Inspect by standing beside the patient.
  3. Inspect from the patient's right side.
  4. Inspect for symmetry and visible peristalsis.
  5. Ask the patient to deep-breathe and inspect.

[nixon_s]

Answer to Question 1

Correct Answer: 2
The nurse should anticipate hearing tympany over air-filled organs such as gas-filled intestines. Intestines that are stool-filled will sound dull. The nurse should percuss several areas within each quadrant of the abdomen, using a systematic path. The nurse should percuss over the spleen, liver, and kidneys and should anticipate hearing a dull sound over the liver.

Answer to Question 2

Correct Answer: 1, 3, 4, 5
The nurse should inspect the abdomen under a good light source that is shining across the abdomen. The nurse sits at the right side of the patient and notes symmetry, distention, masses, visible peristalsis, and respiratory movements. If masses are detected, the nurse asks the patient to take a deep breath. This reduces the size of the abdominal cavity and makes any abnormality more visible. Inspection is performed by sitting by the patient's right side, where the nurse is in the best position to note conditions and deviations from normal.