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Health Assessment Final Exam Study Guide Latest Updated 2024
Typology: Exams
1 / 99
Nursing Academy College93 pag.
Intro to Health Assessment 10 questions
The nursing process
The nursing process is a sequential method of problem solving that nurses use and includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
What step of the nursing process includes data collection by health history, physical examination, and interview?
a. Planning b. Diagnosis c. Evaluation d. Assessment ANS: D Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2).
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
a. Establish priorities. b. Identify expected outcomes. c. Evaluate the individual’s condition, and compare actual outcomes with expected outcomes. d. Interpret data, and then identify clusters of cues and make inferences.
ANS: C Evaluation is the next step after the implementation phase of the nursing process. During this step, the nurse evaluates the individual’s condition and compares the actual outcomes with expected outcomes (See Figure 1-2).
Assessment Phases
Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning.
ANS: A Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct.
When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?
a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care
ANS: C Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care
The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?
a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities.
ANS: D The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.
The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patient’s body systems before proceeding with palpation.
ANS: B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. A focused assessment is significantly more than a “quick glance.”
Identifying priority assessments
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?
a. Patient with postoperative pain b. Newly diagnosed patient with diabetes who needs diabetic teaching c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath and respiratory distress
ANS: D First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1).
When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. Severely abnormal vital signs
ANS: C Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1).
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing
ANS: A First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems.
Assessment techniques
When performing a physical assessment, the first technique the nurse will always use is:
a. Palpation. b. Inspection. c. Percussion. d. Auscultation.
ANS: B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.
The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s skin temperature?
a. Fingertips; they are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve s d. area. ANS: B
The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The other responses are not useful for palpation.
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a. Palpation b. Inspection c. Percussion d. Auscultation ANS: A Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing.
The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant b. Palpating the kidneys and uterus c. Assessing pulsations and vibrations d. Assessing the presence of tenderness and pain ANS: B Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a. Percussing once over each area b. Quickly lifting the striking finger after each stroke c. Striking with the fingertip, not the finger pad d. Using the wrist to make the strikes, not the arm ANS: A
For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm.
The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation ANS: A Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain.
An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a. Using the large full circle of light when assessing pupils that are not dilated b. Rotating the lens selector dial to the black numbers to compensate for astigmatism c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating the lens selector dial to bring the object into focus ANS: D The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus.
When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt to perform the entire physical examination during one visit. c. Speak loudly and slowly because most aging adults have hearing deficits.
d. Arrange the sequence of the examination to allow as few position changes as possible.
ANS: D When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially important with the older person because other senses may be diminished.
Therapeutic Communication A pregnant woman states, “I just know labor will be so painful that I won’t be able to stand it. I know it sounds awful, but I really dread going into labor.” The nurse responds by stating, “Oh, don’t worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain.” Which statement is true regarding this response? The nurse’s reply was a:
a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fe c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated with d. medication.
ANS: B By providing false assurance or reassurance, this courage builder relieves the woman’s anxiety and gives the nurse the false sense of having provided comfort. However, for the woman, providing false assurance or reassurance actually closes off communication, trivializes her anxiety, and effectively denies any further talk of it.
As the nurse enters a patient’s room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, “I’m so afraid of, um, you know.” The nurse’s most therapeutic response would be to say in a gentle manner:
a. “You’re afraid you might lose your breast?” b. “No, I’m not sure what you are talking about.” c. “I’ll wait here until you get yourself under control, and then we can talk.” d. “I can see that you are very upset. Perhaps we should discuss this later.”
ANS: A Reflection echoes the patient’s words, repeating part of what the person has just said. Reflection can also help express the feelings behind a person’s words.
Erikson’s developmental stages
Erikson's psychosocial crisis stages (syntonic v dystonic)
Freudian psycho- sexual stages
life stage / relationships / issues basic virtue and second named strength (potential positive outcomes from each crisis)
maladaptation / malignancy (potential negative outcome
Hope and Drive Sensory Distortion / Withdrawal
Purpose and Direction
Ruthlessness / Inhibition
Competence and Method
Narrow Virtuosity / Inertia
Puberty and Genitality
adolescent / peers, groups, influences / resolving identity and direction, becoming a grown-up
Fidelity and Devotion
Fanaticism / Repudiation
Love and Affiliation Promiscuity / Exclusivity
Wisdom and Renunciation
Presumption / Disdain
Peripheral Vascular 5 Capillary Refill The nurse is performing an assessment on an adult. The adult’s vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further.
d. Consider this a normal capillary refill time that requires no further assessment.
ANS: C Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.
Pedal Pulse
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?
a. Behind the knee b. Over the lateral malleolus c. In the groove behind the medial malleolus d. Lateral to the extensor tendon of the great toe
ANS: D The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. No pulse is palpated at the lateral malleolus.
Homan’s Test
dorsiflexion sign is considered a sign of deep vein thrombosis (DVT). It was defined by John Homans in 1941 as discomfort behind the knee on forced dorsiflexion of the foot
Lymph Drainage
During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?
a. Venous stasis b. Lymphedema c. Arteriosclerosis d. Deep-vein thrombosis
ANS: B
Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and lymphedema can impede drainage of lymph. The other responses are not correct.
Arterial Vs. Venous Insufficiency
During a routine office visit, a patient takes off his shoes and shows the nurse “this awful sore that won’t heal.” On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:
a. Varicosities. b. Venous stasis ulcer. c. Arterial ischemic ulcer. d. Deep-vein thrombophlebitis.
ANS: C Arterial ischemic ulcers occur at the toes, metatarsal heads, heels, and lateral ankle and are characterized by a pale ischemic base, well-defined edges, and no bleeding. (See Table 20-5 for a description of varicose veins and deep- vein thrombophlebitis. See Table 20-4 for a description of venous stasis ulcers.)
A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient’s lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply.
a. Intense, sharp pain, with the deep muscle tender to the touch b. Aching, tired pain, with a feeling of fullness c. Pain that is worse at the end of the day d. Sudden onset e. Warm, red, and swollen calf f. Pain that is relieved with elevation of the leg
ANS: A, D, E Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems.
A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. a. Patient has a history of diabetes and cigarette smoking. b. Skin of the patient is pale and cool. c. His ankles have two small, weeping ulcers. d. Patient works long hours sitting at a computer desk. e. He states that the pain gets worse when walking. f. Patient states that the pain is worse at the end of the day. ANS: A, B, E Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset with exertion and is relieved with rest or dangling. The skin appears cool and pale (see Table 20-3). The other responses reflect chronic venous problems.
A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with the left leg. a. Venous obstruction of b. Claudication due to venous abnormalities in c. Ischemia caused by a partial blockage of an artery supplying d. Ischemia caused by the complete blockage of an artery supplying ANS: C Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.
The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? a. Woman in her second month of pregnancy b. Person who has been on bed rest for 4 days c. Person with a 30-year, 1 pack per day smoking habit d. Older adult taking anticoagulant medication ANS: B
People who undergo prolonged standing, sitting, or bed rest are at risk for venous disease. Hypercoagulable (not anticoagulated) states and vein-wall trauma also place the person at risk for venous disease. Obesity and the late months of pregnancy are also risk factors.
A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
a. Claudication. b. Sore muscles. c. Muscle cramps. d. Venous insufficiency.
ANS: A Intermittent claudication feels like a cramp and is usually relieved by rest within 2 minutes. The other responses are not correct.
A patient complains of leg pain that wakes him at night. He states that he “has been having problems” with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed “a sore” on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing:
a. Pain related to lymphatic abnormalities. b. Problems related to arterial insufficiency. c. Problems related to venous insufficiency. d. Pain related to musculoskeletal abnormalities.
ANS: B Night leg pain is common in aging adults and may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.
A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?
a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds
d. Brownish discoloration to the skin of the lower leg
ANS: D A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.
During an assessment, the nurse has elevated a patient’s legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be:
a. Significant elevational pallor. b. Venous filling within 15 seconds. c. No change in the coloration of the skin. d. Color returning to the feet within 20 seconds of assuming a sitting position.
ANS: B In this test, it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Significant elevational pallor, as well as delayed venous filling, occurs with arterial insufficiency.
During a routine office visit, a patient takes off his shoes and shows the nurse “this awful sore that won’t heal.” On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:
a. Varicosities. b. Venous stasis ulcer. c. Arterial ischemic ulcer. d. Deep-vein thrombophlebitis.
ANS: C Arterial ischemic ulcers occur at the toes, metatarsal heads, heels, and lateral ankle and are characterized by a pale ischemic base, well-defined edges, and no bleeding. (See Table 20-5 for a description of varicose veins and deep- vein thrombophlebitis. See Table 20-4 for a description of venous stasis ulcers.) DIF: Cognitive Level: Analyzing (Analysis) REF: p. 533
Skin, Hair, & Nails 5 questions
Terminology (Macule, papule)
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, “What causes these liver spots?” The nurse tells her, “They are:
a. “Signs of decreased hematocrit related to anemia.” b. “Due to the destruction of melanin in your skin from exposure to the sun.” c. “Clusters of melanocytes that appear after extensive sun exposure.” d. “Areas of hyperpigmentation related to decreased perfusion and vasoconstriction.”
ANS: C Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.
The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient?
a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face
ANS: D With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots.
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull’s eye pattern across his midriff and behind his knees. The nurse suspects:
a. Rubeola. b. Lyme disease. c. Allergy to mosquito bites. d. Rocky Mountain spotted fever. ANS: B
Lyme disease occurs in people who spend time outdoors in May through September. The first disease state exhibits the distinctive bull’s eye and a red macular or papular rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5 cm or larger, and is usually in the axilla, midriff, inguinal, or behind the knee, with regional lymphadenopathy. A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma ANS: B Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule. ANS: D A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.
Skin Cancer Assessment
. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months.
b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.
ANS: B The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.
A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and “stuck on” his skin. Which is the best prediction?
a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous
ANS: D Seborrheic keratoses appear like dark, greasy, “stuck-on” lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are skin tags and are not precancerous.
Nail Abnormalities
A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient’s fingernails?
a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines
ANS: C
Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 12-13 for descriptions of the other terms.)
Abdomen 8 Questions
Abdominal Assessment
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 refer the person and should not continue to palpate it. An enlarged spleen is friable and can easily rupture with overpalpation. 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. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line d. Dull percussion note in the left upper quadrant at the midclavicular 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).
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.
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. 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.
ANS: B With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.
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
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 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. 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.
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.
ANS: B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent.
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. The nurse should:
a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d. Consider this finding as normal, and proceed with the examination.
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.
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. Intra-abdominal bleeding b. Constipation c. Umbilical hernia d. Abdominal tumor
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.
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.
ANS: D 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.
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.
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
Special Population Considerations 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. ANS: B Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct.
During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by: 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. 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.”
At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton 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.
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.
ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases.
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. 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.
ANS: B