Nursing Health Assessment The Foundation of Clinical Practice 3rd Edition by Patricia M. Dillon Test Bank

Nursing Health Assessment The Foundation of Clinical Practice  3rd Edition by Patricia M. Dillon  Test Bank
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Chapter 09: Assessing the Abdomen

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. Which structure of the gastrointestinal (GI) system is found in the right upper quadrant (RUQ) and is the primary site of absorption?
1)
Stomach
2)
Duodenum
3)
Sigmoid
4)
Large intestine

____ 2. The patient is complaining of left upper quadrant (LUQ) pain. Based on this data which does the nurse suspect?
1)
Ruptured spleen
2)
Pneumonia
3)
Hepatitis
4)
Duodenal ulcer

____ 3. Which is the main site for metabolizing drugs which may become impaired with the aging process?
1)
Stomach
2)
Liver
3)
Spleen
4)
Large intestine

____ 4. The nurse is assessing a patient who is admitted to the emergency department (ED) for an acetaminophen overdose. Which will the nurse monitor this patient for based on this data?
1)
Diarrhea
2)
Constipation
3)
Gastrointestinal bleeding
4)
Hepatic necrosis

____ 5. Which structure is found in the midline of the abdomen?
1)
Aorta
2)
Femoral artery
3)
Umbilical artery
4)
Superior vena cava

____ 6. The nurse is assessing a patient who is prescribed an anticholinergic agent. Which assessment finding indicates the patient is experiencing an adverse reaction to the drug?
1)
GI bleeding
2)
Hepatic necrosis
3)
Diarrhea
4)
Paralytic ileus

____ 7. What factor explains the protruding abdomen of an infant?
1)
Weak spinal muscles
2)
Weak abdominal muscles
3)
Bladder pressure above the symphysis pubis
4)
Enlarged liver

____ 8. Which of the following changes to bowel sounds occurs during pregnancy?
1)
Hypoactivity
2)
Hyperactivity
3)
Absent
4)
Normal

____ 9. Which gastrointestinal (GI) changes is not anticipated when assessing an older adult patient?
1)
Changes to dentation
2)
An increase in muscle mass
3)
Painful mastication
4)
A decrease in liver function

____ 10. Which disease process is more likely to occur in the Jewish population?
1)
Colon cancer
2)
Pancreatitis
3)
Thalassemia
4)
Sickle cell anemia

____ 11. The Rovsings sign and iliopsoas muscle test are useful to determine the presence of which disease process?
1)
Appendicitis
2)
Cholecystitis
3)
Duodenal ulcer
4)
Hepatomegaly

____ 12. The nurse notes a positive Murphy sign during the physical assessment. Which does the nurse suspect based on this data?
1)
Ascites
2)
Appendicitis
3)
Cholecystitis
4)
Pelvic abscess

____ 13. When taking the health history of a patient who presents with acute abdominal pain, which is the priority action by the nurse?
1)
Administering pain medication
2)
Collecting detailed demographic information
3)
Exploring the past history of GI illness
4)
Assessing vital signs

____ 14. Which is a life threatening cause of abdominal pain?
1)
Abdominal aortic aneurysm (AAA)
2)
Cholecystitis
3)
Gastroesophageal reflux disease (GERD)
4)
Sickle cell disease

____ 15. The nurse is providing care to a patient who reports diffuse abdominal pain. Upon assessment, the nurse notes absent bowel sounds and abdominal distension. Based on this data which medical diagnosis does the nurse suspect?
1)
Appendicitis
2)
Bowel obstruction
3)
Cirrhosis
4)
Cholelithiasis

____ 16. Which finding on the abdominal exam would indicate the need for further evaluation?
1)
A flat abdomen in a young adult patient within normal weight range for height
2)
Visible peristalsis in a thin child
3)
A slight pulsation in the epigastric region of an adult patient
4)
Presence of spider angiomas on the abdomen

____ 17. The nurse notes a positive shifting dullness. Which diagnosis does this assessment finding support?
1)
Ascites
2)
Liver enlargement
3)
Pancreatitis
4)
An abdominal mass

____ 18. How long do you listen to each quadrant to determine that bowel sounds are absent?
1)
30 seconds
2)
60 seconds
3)
2 minutes
4)
5 minutes

____ 19. Which is the correct sequence for the abdominal exam?
1)
Inspection, palpation, percussion, and auscultation
2)
Inspection, percussion, palpation, and auscultation
3)
Inspection, auscultation, percussion, and palpation
4)
Inspection, auscultation, palpation, and percussion

____ 20. The nurse places the nondominant hand over the costovertebral angle (CVA) and strikes it with the dominant hand. This tests for tenderness in which organ?
1)
Spleen
2)
Kidney
3)
Liver
4)
Bladder

____ 21. The nurse is assessing an adolescent patient admitted to the emergency department (ED) with right lower quadrant (RLQ) pain. What test can be done to assess for appendicitis?
1)
Murphy sign
2)
Iliopsoas muscle test
3)
CVA tenderness
4)
Scratch test

____ 22. The nurse auscultates for bowel sounds. What is the normal frequency of bowel sounds?
1)
Every 5 to 15 seconds
2)
Every 15 to 30 seconds
3)
Every 30 to 60 seconds
4)
Every 5 to 7 minutes

____ 23. The nurse attempts to elicit rebound tenderness. Which finding indicates positive rebound tenderness?
1)
Pain during light palpation over the affected area
2)
Pain during deep palpation over the affected area
3)
Pain upon gradual withdrawal of fingers after light palpation
4)
Pain upon sudden withdrawal of fingers after deep palpation

____ 24. While inspecting the adolescent patients abdomen, the nurse may see aortic pulsations in which area?
1)
Epigastric
2)
Right inguinal
3)
Hypogastric
4)
Left lumbar

____ 25. The nurse is providing care for an adult patient admitted to the hospital with hepatic cirrhosis. Auscultation of the abdomen is included in the assessment. Which sound suggests increased collateral circulation between the portal and the systemic venous systems?
1)
Bruit
2)
Borborygmi
3)
Friction rub
4)
Venous hum

____ 26. Which sound would the nurse expect to elicit when percussing the liver?
1)
Resonance
2)
Hyperresonance
3)
Dullness
4)
Tympany

____ 27. Which is the normal liver span at the midclavicular line?
1)
3 to 6 cm
2)
4 to 8 cm
3)
6 to 12 cm
4)
12 to 16 cm

____ 28. Aside from percussion, which other test may be performed to locate the inferior border of the liver?
1)
Fluid wave test
2)
Rebound test
3)
Obturator test
4)
Scratch test

____ 29. An older adult patient is admitted to the hospital with blunt trauma to the abdomen after an auto accident. Which finding may indicate intra-abdominal bleeding?
1)
Borborygmi
2)
Everted umbilicus
3)
Visible peristaltic waves
4)
Discoloration around the umbilicus

____ 30. Which is a term that indicates hyperactive peristalsis?
1)
Succession splash
2)
Venous hum
3)
Friction rub
4)
Scratch test

____ 31. Which assessment data indicates the patient is experiencing hypoactive bowel sounds?
1)
More than 30 clicks per minute
2)
More than 40 clicks per minute
3)
Less than 5 clicks per minute
4)
Less than 20 clicks per minute

____ 32. The nurse is assessing a patients bladder. Which action is accurate if ascites is noted?
1)
Preparing for bladder catheterization
2)
Documenting this has a normal finding
3)
Auscultating the heart and lungs
4)
Percussing the abdomen for shifting dullness

____ 33. Which type of bowel sound may be indicative of an early bowel obstruction?
1)
Hyperperistaltic bowel sounds
2)
Hypoperistaltic bowel sounds
3)
Absent bowel sounds
4)
Epigastric bowel sounds

____ 34. Which action by the nurse is appropriate when attempting to locate the spleen during the abdominal assessment?
1)
Percussing over the 9th to the 11th ribs at the midaxillary line
2)
Performing the scratch test
3)
Auscultating for venous hums
4)
Palpating for the apical pulse

____ 35. Which structure is located in the right upper quadrant (RUQ) of the abdomen?
1)
Spleen
2)
Stomach
3)
Sigmoid
4)
Liver

____ 36. Which structure is located in the left upper quadrant (LUQ) of the abdomen?
1)
Liver
2)
Spleen
3)
Appendix
4)
Sigmoid

____ 37. Which structure is located in the right lower quadrant (RLQ) of the abdomen?
1)
Liver
2)
Stomach
3)
Cecum
4)
Sigmoid
Chapter 09: Assessing the Abdomen
Answer Section

MULTIPLE CHOICE

1. ANS: 2
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 260
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Digestion
Difficulty: Easy

Feedback
1
The stomach, found in the left upper quadrant, turns the food bolus into chyme.
2
The duodenum is the primary site for digestion, especially chemical digestion. It is located in the RUQ.
3
The sigmoid colon is found in the left upper quadrant.
4
The large intestine primarily reabsorbs water.

PTS: 1 CON: Digestion

2. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 247
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension (Understanding)
Concept: Digestion, Comfort
Difficulty: Easy

Feedback
1
A ruptured spleen would manifest with pain in the LUQ.
2
Pneumonia would manifest with pain in the right upper quadrant (RUQ).
3
Hepatitis would manifest with pain in the right upper quadrant (RUQ).
4
A duodenal ulcer would manifest with pain in the right upper quadrant (RUQ).

PTS: 1 CON: Digestion | Comfort

3. ANS: 2
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 246
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application (Applying)
Concept: Metabolism, Medications
Difficulty: Moderate

Feedback
1
The stomach turns food bolus into chyme.
2
The liver detoxifies a variety of substances such as drugs and alcohol. This function may become impaired with the aging process.
3
The spleen produces and stores red (RBCs) and white (WBCs) blood cells.
4
The large intestine reabsorbs water.

PTS: 1 CON: Metabolism | Medications

4. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 252
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive level: Application (Applying)
Concept: Medications, Assessment
Difficulty: Moderate

Feedback
1
Diarrhea is not a known adverse effect associated with an acetaminophen overdose. Diarrhea may occur with magnesium hydroxide.
2
Constipation is not a known adverse effect associated with an acetaminophen overdose. Constipation may occur with aluminum hydroxide.
3
Gastrointestinal bleeding is not a known adverse effect associated with an acetaminophen overdose. Gastrointestinal bleeding may occur with aspirin.
4
Hepatic necrosis is a known adverse reaction that can occur from toxic levels of acetaminophen.

PTS: 1 CON: Medications | Assessment

5. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 261
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment
Difficulty: Easy

Feedback
1
The aorta is a structure that is found in the midline of the abdomen.
2
The femoral artery is not a structure that is found in the midline of the abdomen.
3
The umbilical artery is not a structure that is found in the midline of the abdomen.
4
The superior vena cava is not a structure that is found in the midline of the abdomen.

PTS: 1 CON: Assessment

6. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 252
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive level: Application (Applying)
Concept: Medication, Assessment
Difficulty: Moderate

Feedback
1
GI bleeding is an adverse reaction associated with aspirin, not an anticholinergic drug.
2
Hepatic necrosis is an adverse reaction associated with toxic levels of acetaminophen, not an anticholinergic drug.
3
Diarrhea is an adverse reaction associated with many drugs, but this is not an adverse reaction associated with an anticholinergic drug.
4
Paralytic ileus is an adverse reaction associated with anticholinergic drugs.

PTS: 1 CON: Medication | Assessment

7. ANS: 2
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 245
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge (Remembering)
Concept: Development, Assessment
Difficulty: Easy

Feedback
1
Weak spinal muscles are not the reason for the infants protruding abdomen.
2
Because the infants abdominal muscles are weak, the abdomen normally protrudes.
3
Bladder pressure above the symphysis pubis is not the reason for the infants protruding abdomen.
4
An enlarged liver is not the reason for the infants protruding abdomen.

PTS: 1 CON: Development | Assessment

8. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective:
Chapter page reference: 246
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Pregnancy, Assessment
Difficulty: Easy

Feedback
1
There are diminished bowel sounds in the pregnant patient as a result of the bowels being compressed by the fetus.
2
Hyperactivity of bowel sounds is not expected during pregnancy.
3
Absent bowel sounds are not expected during pregnancy.
4
Normal bowel sounds are typically not an expected finding during pregnancy.

PTS: 1 CON: Pregnancy | Assessment

9. ANS: 2
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 246
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Digestion, Assessment
Difficulty: Easy

Feedback
1
Changes in dentation are an expected assessment finding for an older adult patient.
2
The nurse would anticipate a decrease, not an increase, in muscle mass when assessing the older adult patient.
3
Painful mastication often occurs in older adult patients. This is an expected assessment finding.
4
A decrease in liver function is an expected assessment finding for an older adult patient.

PTS: 1 CON: Digestion | Assessment

10. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 246
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Diversity, Assessment
Difficulty: Easy

Feedback
1
A higher incidence of colon cancer exists in the Ashkenazi Jewish population because they are believed to have a gene linked to the development of familial colorectal cancer.
2
Native Americans have a high incidence of pancreatitis.
3
Thalassemia is more commonly seen in persons of Greek or Italian descent.
4
Sickle cell anemia is more commonly seen in African Americans.

PTS: 1 CON: Diversity | Assessment

11. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 271
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
Rovsing sign indicates peritoneal irritation and/or appendicitis, and iliopsoas muscle irritation is caused by an inflamed or perforated appendix.
2
Murphy sign is a test for cholecystitis.
3
These assessments are not useful to determine the presence of a duodenal ulcer.
4
These assessments are not useful to determine the presence of hepatomegaly.

PTS: 1 CON: Assessment

12. ANS: 3
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 272
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment, Digestion
Difficulty: Moderate

Feedback
1
Fluid wave and shifting dullness tests indicate ascites.
2
Rebound and a positive Rovsing sign indicate appendicitis.
3
A positive Murphy sign is indicative of cholecystitis or carcinoma of the gallbladder.
4
A positive Murphy sign is not indicative of a pelvic abscess.

PTS: 1 CON: Assessment | Digestion

13. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 247-249
Heading: Assessment History
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive level: Analysis (Analyzing)
Concept: Comfort, Assessment
Difficulty: Difficult

Feedback
1
Although administering pain medication is an important action, this is not the priority in this situation.
2
Although collecting detailed demographic information is important, this is not the priority in this situation.
3
Although exploring the past medication history of GI illness is important, this is not the priority in this situation.
4
Assessing vital signs, which includes a pain assessment, is the priority in this situation.

PTS: 1 CON: Comfort | Assessment

14. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 257
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Synthesis (Creating)
Concept: Comfort
Difficulty: Difficult

Feedback
1
An AAA can be life-threatening and is an outpouching of the abdominal aorta, one of the major blood vessels.
2
Although cholecystitis can cause abdominal pain, this condition is not life threatening.
3
Although GERD can cause abdominal pain, this condition is not life threatening.
4
Although sickle cell disease can cause abdominal pain, this condition is not life threatening.

PTS: 1 CON: Comfort

15. ANS: 2
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 264
Heading: Physical Assessment
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis (Analyzing)
Concept: Assessment, Bowel Elimination
Difficulty: Difficult

Feedback
1
Appendicitis causes abdominal pain; bowel sounds are absent if the appendix perforates and causes peritonitis.
2
Absent bowel sounds are caused by late bowel obstruction, peritonitis, or paralytic ileus after surgery in which the bowel was manipulated.
3
Cirrhosis may affect liver size.
4
Cholelithiasis causes abdominal pain.

PTS: 1 CON: Assessment | Bowel Elimination

16. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 263
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
A flat abdomen is a normal assessment finding.
2
Visible peristalsis in a child is a normal finding.
3
Slight pulsations are a normal finding.
4
Spider angiomas may be an indication of cirrhosis of the liver and result from portal circulation congestion.

PTS: 1 CON: Assessment

17. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 269
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment, Digestion
Difficulty: Moderate

Feedback
1
Shifting dullness indicates ascitic fluid of greater than 500 mL.
2
Liver enlargement will cause dullness, but it does not shift.
3
Positive shifting dullness is not indicative of pancreatitis.
4
An abdominal mass will cause dullness, but it does not shift.

PTS: 1 CON: Assessment | Digestion

18. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 265
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment, Digestion
Difficulty: Moderate

Feedback
1
The nurse must auscultate for longer than 30 seconds to determine absence of bowel sounds.
2
The nurse must auscultate for longer than 60 seconds to determine absence of bowel sounds.
3
The nurse must auscultate for longer than 2 minutes to determine absence of bowel sounds.
4
Bowel sounds occur every 5 to 15 seconds in an average adult patient. Listen for at least 5 minutes before determining that bowel sounds are absent.

PTS: 1 CON: Assessment | Digestion

19. ANS: 3
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 262
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
This is not the correct order for an abdominal assessment.
2
This is not the correct order for an abdominal assessment.
3
It is important to auscultate before percussion and palpation because the manipulation that occurs with these techniques may increase the frequency of bowel sounds.
4
This is not the correct order for an abdominal assessment.

PTS: 1 CON: Assessment

20. ANS: 2
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 269
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension (Understanding)
Concept: Assessment, Elimination
Difficulty: Easy

Feedback
1
The spleen is assessed from the left upper quadrant (LUQ) or right axillary line.
2
Fist or blunt percussion can be used to assess the kidneys for tenderness.
3
The liver is assessed in the right upper quadrant (RUQ).
4
The bladder is assessed in the lower quadrants at the midline above the symphysis pubis.

PTS: 1 CON: Assessment | Elimination

21. ANS: 2
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 271
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
The Murphy sign is for cholecystitis.
2
The iliopsoas, obturator, Rovsing signs, and rebound tenderness are tests that can be done to assess for appendicitis.
3
CVA tenderness assesses for renal problems.
4
The scratch test is useful in locating the lower edge of the liver.

PTS: 1 CON: Assessment

22. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 265
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment, Digestion
Difficulty: Easy

Feedback
1
Bowel sounds occur every 5 to 15 seconds in an average adult patient.
2
This finding indicates hypoactive bowel sounds.
3
This finding indicates hypoactive bowel sounds.
4
This finding indicates the absence of bowel sounds.

PTS: 1 CON: Assessment | Digestion

23. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 271
Heading: Physical Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis (Analyzing)
Concept: Assessment, Comfort
Difficulty: Difficult

Feedback
1
Light palpation is not used to elicit rebound tenderness.
2
This is not the nursing action to elicit rebound tenderness.
3
This is not the nursing action to elicit rebound tenderness.
4
To elicit rebound tenderness, place your hand perpendicular to the abdomen and press firmly and slowly and then release quickly.

PTS: 1 CON: Assessment | Comfort

24. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 263
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment
Difficulty: Easy

Feedback
1
Aortic pulsations may be visible over the aorta in the epigastric region.
2
Pulsations visible in the right inguinal area is not a normal finding.
3
Pulsations visible in the hypogastric area is not a normal finding.
4
Pulsations visible in the left lumbar area is not a normal finding.

PTS: 1 CON: Assessment

25. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 266
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
Bruits are arterial sounds.
2
Borborygmi are loud bowel sounds.
3
Friction rubs occur with inflamed organs or tumors.
4
Venous hums are indicative of venous portal hypertension and liver disease.

PTS: 1 CON: Assessment

26. ANS: 3
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 267
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment
Difficulty: Easy

Feedback
1
Resonance is a respiratory percussion sound.
2
Hyperresonance is a respiratory percussion sound.
3
Dullness should be heard over the liver (around the fifth to seventh intercostal space).
4
Tympany is percussed over the stomach or intestines filled with air or gas.

PTS: 1 CON: Assessment

27. ANS: 3
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 268
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment
Difficulty: Easy

Feedback
1
The normal liver span at the midclavicular line is not 3 to 6 cm.
2
The normal liver span at the midclavicular line is not 4 to 8 cm.
3
The normal liver span at the midclavicular line is 6 to 12 cm.
4
The normal liver span at the midclavicular line is not 12 to 16 cm.

PTS: 1 CON: Assessment

28. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 265
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment
Difficulty: Easy

Feedback
1
The fluid wave test is used to assess for ascites.
2
The rebound test is used to assess for peritonitis or appendicitis.
3
The obturator test is used to assess for peritonitis or appendicitis.
4
To help you locate the lower edge of the liver, where it is difficult to percuss, use the scratch test: Place your stethoscope over the liver in the left upper quadrant (LUQ) and gently scratch the abdomen from the left lower quadrant (LLQ) up until the sound is heard. Once the stethoscope is over the liver, the sound is transmitted by the liver and heard, identifying the lower edge of the liver.

PTS: 1 CON: Assessment

29. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 263
Heading: Physical Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
Borborygmi is the term used to describe hyperactive bowel sounds.
2
An everted umbilicus is often a normal finding for pregnant patients.
3
Visible peristaltic waves can be a normal finding for pediatric patients.
4
Discoloration around the umbilicus (Cullen sign) indicates hemorrhagic pancreatitis or intraperitoneal bleeding.

PTS: 1 CON: Assessment

30. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 265
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
Succession splash is a term used to describe hyperactive peristalsis.
2
A venous hum is indicative of venous portal hypertension and liver disease.
3
A friction rub indicates inflammation of the peritoneal surface.
4
A scratch test is used to locate the inferior edge of the liver.

PTS: 1 CON: Assessment

31. ANS: 3
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 265
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
More than 30 clicks per minute indicates hyperactive, not hypoactive, bowel sounds.
2
More than 40 clicks per minute indicates hyperactive, not hypoactive, bowel sounds.
3
Less than 5 clicks per minute indicates hypoactive bowel sounds.
4
Less than 20 clicks per minute would indicate normal bowels sounds.

PTS: 1 CON: Assessment

32. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 269
Heading: Physical Assessment
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
Ascites is not an indication of bladder distention; therefore, this action is not accurate.
2
Ascites is not a normal finding; therefore, this action is not accurate.
3
Ascites does not indicate the need to auscultate heart and lung sounds.
4
When assessing a patient with ascites the accurate nursing action is to percuss the abdomen to determine if shifting dullness is noted.

PTS: 1 CON: Assessment

33. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 265
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
Hyperperistalsis can be a sign of an early bowel obstruction.
2
Hypoperistalsis is not a sign of an early bowel obstruction.
3
Absent bowel sounds are a not a sign of an early bowel obstruction.
4
Epigastric bowel sounds are not a sign of an early bowel obstruction.

PTS: 1 CON: Assessment

34. ANS: 1
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 268
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application (Applying)
Concept: Assessment
Difficulty: Moderate

Feedback
1
Dullness of the normal spleen will be noted around the 9th to the 11th ribs.
2
The scratch test is used to locate the liver.
3
Venous hums indicate liver disease.
4
Palpating the apical pulse is not a procedure used to locate the spleen.

PTS: 1 CON: Assessment

35. ANS: 4
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 260
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment
Difficulty: Easy

Feedback
1
The spleen is located in the left upper quadrant.
2
The stomach is located in the left upper quadrant.
3
The sigmoid colon is located in the left lower quadrant.
4
The liver is located in the RUQ.

PTS: 1 CON: Assessment

36. ANS: 2
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 260
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment
Difficulty: Easy

Feedback
1
The liver is located in the right upper quadrant.
2
The spleen is located in the LUQ.
3
The appendix is located in the right lower quadrant.
4
The sigmoid is located in the left lower quadrant.

PTS: 1 CON: Assessment

37. ANS: 3
Chapter number and title: 9, Assessing the Abdomen
Chapter learning objective: N/A
Chapter page reference: 260
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension (Understanding)
Concept: Assessment
Difficulty: Easy

Feedback
1
The liver is located in the right upper quadrant.
2
The stomach is located in the left upper quadrant.
3
The cecum is located in the RLQ.
4
The sigmoid is located in the left lower quadrant.

PTS: 1 CON: Assessment

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