Nursing Health Assessment Test Bank Questions

Abdomen Physical Examination and Health Assessment MULTIPLE CHOICE 1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Tympany b. Dullness c. Resonance d. Hyperresonance ANS: B Abdominal percussion is performed to assess the relative density of abdominal contents, locate organs, and screen for abnormal fluid or masses in the abdomen. The liver is a solid organ which is located in the right upper quadrant and would elicit a dull percussion note. Tympany is heard over air-filled organs such as the stomach and intestines. It is the predominant sound that should be heard over the intestines because air in the intestines rises to the surface when the person is supine. Resonance is a low-pitched, clear, hollow sound that predominates in health lung tissue. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as with gaseous distention of the intestines in the abdomen or emphysema in the lungs. Since the liver is a solid organ located in the right upper quadrant, it should elicit a dull sound when percussed. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 2. Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum c. Gallbladder d. Sigmoid colon ANS: D The sigmoid colon is located in the left lower quadrant of the abdomen. The duodenum, or first part of the small intestine, and the gallbladder are located in the right upper abdominal quadrant. The sigmoid colon then is the structure that is located in the left lower abdominal quadrant. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Health Promotion and Maintenance 3. A patient is having difficulty swallowing medications and food. How should the nurse document this? a. Aphasia b. Anorexia c. Dysphasia d. Dysphagia ANS: D Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region b. Inspect and palpate in the epigastric region c. Auscultate and percuss in the inguinal region d. Percuss and palpate the midline area above the suprapubic bone ANS: D The bladder is located in the suprapubic area (above the pubic bone) and if distended would elicit a dull sound when percussed and feel firm to palpation. However, this technique has been found to be unreliable and bedside bladder scanning with ultrasound is commonly used to estimate bladder volume. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is aware that what change may occur in the gastrointestinal system with aging? a. Increased salivation b. Increased liver size c. Increased esophageal emptying d. Decreased gastric acid secretion ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a. The spleen can be enlarged as a result of trauma. b. The spleen is normally felt on routine palpation. c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size. d. An enlarged spleen should not be palpated because it can easily rupture. ANS: D If an enlarged spleen is felt, then the nurse should not continue to palpate it but refer the patient to a physician. An enlarged spleen is friable and can easily rupture with overpalpation. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 7. A patient’s abdomen is bulging and stretched in appearance. How should the nurse document this finding? a. Obese b. Scaphoid c. Herniated d. Protuberant ANS: D A bulging and stretched abdomen is described as protuberant. A protuberant abdomen is rounded, bulging, and stretched. A scaphoid abdomen caves inward. An obese abdomen appears uniformly rounded with a sunken umbilicus. A hernia is a protrusion of the abdominal viscera through an abnormal opening in the abdominal muscle wall. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. The nurse is describing a scaphoid abdomen. When assessing the contour of the abdomen from the rib margin to the pubic bone, what would the contour look like? a. Flat b. Convex c. Bulging d. Concave ANS: D Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane. The contour describes the nutritional state and normally ranges from flat to round. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. What does the nurse suspect? a. Pulsations of the renal arteries b. Normal abdominal aortic pulsations c. Pulsations of the inferior vena cava d. Increased peristalsis from a bowel obstruction ANS: B Pulsations from the aorta are normally observed beneath the skin in the epigastric area, particularly in thin people who have good muscle wall relaxation. Pulsations of the renal arteries are not visible. The vena cava is a vein, not an artery, and does not have pulsations. Waves of peristalsis are sometimes visible in very thin people and appear as a slow ripple moving obliquely across the abdomen. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 10. A patient has hypoactive bowel sounds. What is a possible cause of this finding? a. Diarrhea b. Peritonitis c. Laxative use d. Gastroenteritis ANS: B Diminished or absent bowel sounds signal decreased gastrointestinal motility which can be caused from inflammation from peritonitis, a paralytic ileus after abdominal surgery, or with a bowel obstruction. Diarrhea, laxative use, and gastroenteritis cause hyperactive, not hypoactive, bowel sounds. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 11. The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? “We need to determine the areas of tenderness before using percussion and palpation.” b. “Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.” c. “Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination.” d. “Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.” a. ANS: B Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? a. Sound like two pieces of leather being rubbed together b. Are usually high-pitched, gurgling, and irregular sounds c. Are usually loud, high-pitched, rushing, and tinkling sounds d. Originate from the movement of air and fluid through the large intestine ANS: B Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 13. The physician comments that a patient has abdominal borborygmi. What is the best description of this term? a. Hypoactive bowel sounds b. A peritoneal friction rub c. Loud gurgling bowel sounds d. Loud continual humming bowel sounds ANS: C Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling. Upon auscultation borborygmi sounds like loud gurgling bowel sounds. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area b. Tympanic percussion note in the umbilical region c. Dull percussion note in the left upper quadrant at the midclavicular line d. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line ANS: B Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 15. The nurse is assessing the abdomen of a pregnant woman who states she has been having “acid indigestion” all the time. What does the nurse know that esophageal reflux during pregnancy can cause? a. Diarrhea b. Pyrosis c. Dysphagia d. Constipation ANS: B Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 16. The nurse is performing an abdominal assessment. What types of percussion notes can be heard during abdominal assessment? a. Flatness, resonance, and dullness b. Resonance, dullness, and tympany c. Tympany, hyperresonance, and dullness d. Resonance, hyperresonance, and flatness ANS: C Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass. Flatness is not a term used to describe a percussed sound. Resonance is a low-pitched, clear, hollow sound that predominates in healthy lung tissue but not in the abdomen. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 17. An older patient has been diagnosed with pernicious anemia. This disorder could be r/t what condition? a. Increased gastric acid secretion b. Decreased gastric acid secretion c. Delayed gastrointestinal emptying time d. Increased gastrointestinal emptying time ANS: B Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 18. A patient is reporting sharp pain along the costovertebral angles. What does this symptom most often indicate? a. Ovarian infection b. Liver enlargement c. Spleen enlargement d. Kidney inflammation ANS: D Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct. Ovarian infection and liver or spleen enlargement do not cause pain along the costovertebral angles. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 19. A nurse notices that a patient has abdominal ascites. What does this finding indicate? a. Flatus b. Fibroid tumors c. Presence of feces d. Presence of fluid ANS: D Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 20. The nurse notices that a patient has had a black, tarry stool. What should the nurse recognize may cause this finding? a. Gallbladder disease b. Overuse of laxatives c. Gastrointestinal bleeding d. Localized bleeding around the anus ANS: C Stools may be black and tarry (melena) as a result of bleeding in the upper gastrointestinal tract. Red blood in stools occurs with localized bleeding in the rectal or anal areas. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 21. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure? a. Spleen b. Sigmoid c. Appendix d. Gallbladder ANS: C The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant. The spleen is in the left upper quadrant; the sigmoid is in the left lower quadrant; and the gallbladder is in the right upper quadrant. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 22. The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? a. Abdominal tone is increased. b. Abdominal musculature is thinner. c. Abdominal rigidity with an acute abdominal condition is more common. d. The older adult with an acute abdominal condition complains more about pain than the younger person. ANS: B In the older adult, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with an acute abdominal condition is less common in the aging person. The older adult with an acute abdominal condition often complains less about pain than the younger person. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 23. During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this? a. Projectile vomiting b. Hypoactive bowel activity c. Palpable olive-sized mass in the right lower quadrant d. Pronounced peristaltic waves crossing from right to left ANS: A Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 24. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a. A bruit is absent. b. Femoral pulses are increased. c. A pulsating mass is usually present. d. Most are located below the umbilicus. ANS: C Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 25. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient’s abdomen. How long should the nurse listen before reporting absent bowel sounds? a. 1 minute b. 5 minutes c. 10 minutes d. 2 minutes in each quadrant ANS: B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 26. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b. Test for Murphy sign c. Iliopsoas muscle test d. Assess for rebound tenderness ANS: B Normally palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy test). The person feels sharp pain and abruptly stops midway during inspiration. The obturator and iliopsoas muscle tests assess for an inflamed appendix. Although a patient with cholecystitis may have rebound tenderness, the presence of rebound tenderness indicates peritoneal inflammation which could be caused by several things so it is not specific to cholecystitis. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 27. Just before going home, a new mother asks the nurse about the infant’s umbilical cord. Which of these statements is correct ? a. “It should fall off in 10 to 14 days.” b. “It will soften before it falls off.” c. “It contains two veins and one artery.” d. “Skin will cover the area within 1 week.” ANS: A At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton’s jelly. The umbilical stump dries within a week, hardens, and falls off in 10 to 14 days. Skin will cover the area in 3 to 4 weeks. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 28. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympany in the right and left lower quadrants ANS: A A large amount of ascitic fluid produces a dull sound to percussion. Flatness is not a term used to describe a percussed sound. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as with gaseous distention of the intestines in the abdomen, not with ascites or fluid. Tympany normally is the predominant sound heard on abdominal auscultation, but it is not heard with ascites, or fluid, in the abdomen. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 29. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. “No need to worry. Most men your age develop hernias.” b. “A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.” c. “A hernia is the result of prenatal growth abnormalities that are just now causing problems.” d. “I’ll have to have your physician explain this to you.” ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall. The nurse should acknowledge the patient’s concerns and not tell him not to worry about it or refer him to his physician to explain it. It is not a result of prenatal growth abnormalities. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 30. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. How should the nurse proceed? a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Consider this finding as normal, and proceed with the examination. d. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. ANS: C A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 31. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Appendix c. Gallbladder d. Sigmoid colon ANS: A The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 32. The nurse is reviewing information on lactose intolerance and learned that in some racial groups lactase activity (abili ty to digest and absorb lactose) is high at birth but declines to low levels by adulthood. Which ethnic group has the highest potential for lactose-intolerance symptoms in adulthood? a. Asians b. African Americans c. White Americans d. American Indians ANS: D Millions of American adults have the potential for lactose-intolerance symptoms; while 70–80% of White Americans produce lactase adequately into adulthood, only 30% of Mexican Americans, 20% of African Americans, and no American Indians will maintain adequate ability to digest lactose without adverse symptoms. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Health Promotion and Maintenance 33. The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this disorder? a. Hypertension b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal antiinflammatory drugs ANS: D Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the stomach or small intestine. The acid can create a painful open sore that may bleed. Peptic ulcers often occur with the frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infections all of which can cause inflammation and irritation to the stomach lining or mucosa. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential 34. During the change-of-shift report, the student nurse hears that a patient has hepatomegaly. What should the student recognizes that this term means? a. Enlarged liver b. Enlarged spleen c. Distended bowel d. Excessive diarrhea ANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 35. During an assessment, the nurse notices that a patient’s umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? a. Constipation b. Abdominal tumor c. Umbilical hernia d. Intra-abdominal bleeding ANS: C The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 36. During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test? a. Ascites b. Splenomegaly c. Constipation d. Distended bladder ANS: A If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 37. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds. ANS: B The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 38. During a health history, the patient tells the nurse, “I have pain all the time in my stomach. It’s worse 2 hours after I eat, but it gets better if I eat again!” Based on these symptoms, the nurse suspects that the patient has which condition? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may be relieved by eating more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply.) a. Test for fluid wave b. Test for the Murphy sign c. Test for the Blumberg sign d. Test for shifting dullness e. Perform the iliopsoas muscle test ANS: C, E Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation