Chapter 21

Question 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)
Dullness
B)
Tympany
C)
Resonance
D)
Hyperresonance

Answer 1

A

Question 2

• Which structure is located in the left lower quadrant of the abdomen?
  A)
  Liver
  B)
  Duodenum
  C)
  Gallbladder
  D)
  Sigmoid colon

Answer 2

D

Question 3

• A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:
  A)
  aphasia.
  B)
  dysphasia.
  C)
  dysphagia.
  D)
  anorexia.

Answer 3

C

Question 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.

Answer 4

D

Question 5

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:
A)
increased salivation.
B)
increased liver size.
C)
increased esophageal emptying.
D)
decreased gastric acid secretion.

Answer 5

D

Question 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 handlebars. 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 upon routine palpation.
  C)
  If an enlarged spleen is noticed, then the nurse should palpate thoroughly to determine size.
  D)
  An enlarged spleen should not be palpated because it can rupture easily.

Answer 6

D

Question 7

A patient’s abdomen is bulging and stretched in appearance. The nurse should describe this finding as:
A)
obese.
B)
herniated.
C)
scaphoid.
D)
protuberant.

Answer 7

D

Question 8

• The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile.
  A)
  flat
  B)
  convex
  C)
  bulging
  D)
  concave

Answer 8

D

Question 9

• While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:
  A)
  pulsations of the renal arteries.
  B)
  pulsations of the inferior vena cava.
  C)
  normal abdominal aortic pulsations.
  D)
  increased peristalsis from a bowel obstruction.

Answer 9

C

Question 10

• A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
  A)
  diarrhea.
  B)
  peritonitis.
  C)
  laxative use.
  D)
  gastroenteritis.

Answer 10

B

Question 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?
  A)
  “We need to determine areas of tenderness before using percussion and palpation.”
  B)
  “It prevents distortion of bowel sounds that might occur after percussion and palpation.”
  C)
  “It allows the patient more time to relax and therefore be more comfortable with the physical examination.”
  D)
  “This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation.”

Answer 11

B

Question 12

• The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?
  A)
  They are usually loud, high-pitched, rushing, tinkling sounds.
  B)
  They are usually high-pitched, gurgling, irregular sounds.
  C)
  They sound like two pieces of leather being rubbed together.
  D)
  They originate from the movement of air and fluid through the large intestine

Answer 12

B

Question 13

• The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:
  A)
  a loud continuous hum.
  B)
  a peritoneal friction rub.
  C)
  hypoactive bowel sounds.
  D)
  hyperactive bowel sounds.

Answer 13

D

Question 14

• During an abdominal assessment, the nurse would consider which of these findings as normal?
  A)
  The presence of a bruit in the femoral area
  B)
  A tympanic percussion note in the umbilical region
  C)
  A palpable spleen between the ninth and eleventh ribs in the left midaxillary line
  D)
  A dull percussion note in the left upper quadrant at the midclavicular line

Answer 14

B

Question 15

The nurse is assessing the abdomen of a pregnant woman who is complaining of having “acid indigestion” all the time. The nurse knows that esophageal reflux during pregnancy can cause:
A)
diarrhea.
B)
pyrosis.
C)
dysphagia.
D)
constipation.

Answer 15

B

Question 16

• The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:
  A)
  flatness, resonance, and dullness.
  B)
  resonance, dullness, and tympany.
  C)
  tympany, hyperresonance, and dullness.
  D)
  resonance, hyperresonance, and flatness.

Answer 16

C

Question 17

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:
A)
increased gastric acid secretion.
B)
decreased gastric acid secretion.
C)
delayed gastrointestinal emptying time.
D)
increased gastrointestinal emptying time.

Answer 17

B

Question 18

• A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of:
  A)
  ovary infection.
  B)
  liver enlargement.
  C)
  kidney inflammation.
  D)
  spleen enlargement.

Answer 18

C

Question 19

• A nurse notices that a patient has ascites, which indicates the presence of:
  A)
  fluid.
  B)
  feces.
  C)
  flatus.
  D)
  fibroid tumors.

Answer 19

A

Question 20

• The nurse knows that during an abdominal assessment, deep palpation is used to determine:
  A)
  bowel motility.
  B)
  enlarged organs.
  C)
  superficial tenderness.
  D)
  overall impression of skin surface and superficial musculature.

Answer 20

B

Question 21

• The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be:
  A)
  gallbladder disease.
  B)
  overuse of laxatives.
  C)
  gastrointestinal bleeding.
  D)
  localized bleeding around the anus.

Answer 21

C

Question 22

• During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?
  A)
  Spleen
  B)
  Sigmoid
  C)
  Appendix
  D)
  Gallbladder

Answer 22

C

Question 23

The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true?
A)
The abdominal tone is increased.
B)
The abdominal musculature is thinner.
C)
Abdominal rigidity with acute abdominal conditions is more common.
D)
The aging person complains of more pain with an acute abdominal condition than a younger person would.

Answer 23

B

Question 24

• to detect diastasis recti, the nurse should have the patient perform which of these maneuvers?
  A)
  Relax in the supine position.
  B)
  Raise the arms in the left lateral position.
  C)
  Raise the arms over the head while supine.
  D)
  Raise the head while remaining supine.

Answer 24

D

Question 25

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.

Answer 25

C

Question 26

• During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient’s abdomen. Before reporting this finding as “silent bowel sounds” the nurse should listen for at least:
  A)
  1 minute.
  B)
  5 minutes.
  C)
  10 minutes.
  D)
  2 minutes in each quadrant.

Answer 26

B

Question 27

• 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’s sign
  C)
  Assess for rebound tenderness
  D)
  Iliopsoas muscle test

Answer 27

B

Question 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

Answer 28

A

Question 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)
  “This hernia is a result of prenatal growth abnormalities that are just now causing problems.”
  D)
  “I’ll have to have your physician explain this to you.”

Answer 29

B

Question 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 about 10 cm. The nurse should:
  A)
  document the presence of hepatomegaly.
  B)
  ask additional history questions regarding his alcohol intake.
  C)
  describe this as an enlarged liver and refer him to a physician.
  D)
  consider this a normal finding and proceed with the examination.

Answer 30

D

Question 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)
  Sigmoid colon
  C)
  Appendix
  D)
  Gallbladder

Answer 31

A

Question 32

The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group?
A)
African-Americans
B)
Hispanics
C)
Whites
D)
Asians

Answer 32

A

Question 33

The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem?
A)
Hypertension
B)
Streptococcus infections
C)
History of constipation and frequent laxative use
D)
Frequent use of nonsteroidal antiinflammatory drugs

Answer 33

D

Question 34

• During report, the student nurse hears that a patient has “hepatomegaly” and recognizes that this term refers to:
  A)
  an enlarged liver.
  B)
  an enlarged spleen.
  C)
  distended bowel.
  D)
  excessive diarrhea.

Answer 34

A

Question 35

• During an assessment the nurse notices that a patient’s umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition?
  A)
  Intra-abdominal bleeding
  B)
  Constipation
  C)
  Umbilical hernia
  D)
  An abdominal tumor

Answer 35

C

Question 36

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:
A)
splenomegaly.
B)
distended bladder.
C)
constipation.
D)
ascites.

Answer 36

D

Question 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? The nurse should:
  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.

Answer 37

B

Question 38

During a health history, the patient tells the nurse, “I have pain all the time in my stomach. It’s worse two hours after I eat, but it gets better if I eat again!” The nurse suspects that the patient has which condition, based on these symptoms?
A)
Appendicitis
B)
Gastric ulcer
C)
Duodenal ulcer
D)
Cholecystitis

Answer 38

C