Chapter 19 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 19

Question 1

Type: HOTSPOT

The nurse is preparing to perform an abdominal assessment. The client states, Can you point to where my appendix is located? Draw an arrow to the location of the clients appendix.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The vermiform appendix is attached to the large intestines at the cecum.

Global Rationale:

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.

Question 2

Type: HOTSPOT

The nurse is speaking with the client during the focused interview. The client states, My doctor said that my spleen was enlarged. Where is my spleen? Draw an arrow to the location of the spleen.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm.

Global Rationale:

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.

Question 3

Type: MCMA

A client asks the nurse, Whats the purpose of the liver? Which of the following statements would be beneficial for the nurse to share with the client?

Standard Text: Select all that apply.

1. It helps you digest fats.

2. It is an endocrine and exocrine gland.

3. It filters waste from the blood and makes urine.

4. It makes some blood clotting substances.

5. It can help you store certain vitamins.

Correct Answer: 1,4,5

Rationale 1: It helps you digest fats. The liver helps the body digest fats by producing bile.

Rationale 2: It is an endocrine and exocrine gland. The pancreas is an example of an exocrine and endocrine gland.

Rationale 3: It filters waste from the blood and makes urine. The kidneys filter nitrogen waste from the blood and make urine.

Rationale 4: It makes some blood clotting substances. The liver makes blood clotting substances.

Rationale 5: It can help you store certain vitamins. The liver can store certain types of vitamins.

Global Rationale: The liver produces and secretes bile for fat breakdown, but also aids in the metabolism of proteins and carbohydrates. It stores some vitamins, helps with blood coagulation, produces antibodies, and detoxifies some harmful substances. The pancreas is an example of an exocrine and endocrine gland. The kidneys filter nitrogen waste from the blood and make urine.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.

Question 4

Type: MCMA

The nurse is palpating the right upper quadrant of a clients abdomen. Which of the following organs may be assessed during this portion of the assessment?

Standard Text: Select all that apply.

1. Liver

2. Gallbladder

3. Appendix

4. Spleen

5. Stomach

Correct Answer: 1,2

Rationale 1: Liver. The liver is located in the right upper quadrant.

Rationale 2: Gallbladder. The gallbladder is located in the right upper quadrant.

Rationale 3: Appendix. The appendix is located in the right lower quadrant.

Rationale 4: Spleen. The spleen is located in the left upper quadrant.

Rationale 5: Stomach. The stomach is located in the left upper quadrant.

Global Rationale: The liver is located in the right upper quadrant. The gallbladder is located in the right upper quadrant. The appendix is located in the right lower quadrant. The spleen is located in the left upper quadrant. The stomach is located in the left upper quadrant.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.

Question 5

Type: MCSA

A client asks the nurse, Whats the purpose of a gall bladder anyway? My mom lived for many years without her gallbladder after she had to have it taken out. Which of the following information would be beneficial for the nurse to share with this client?

1. You are right. We still dont know the function of the gallbladder.

2. It stores bile until it is needed for digestion of fats.

3. It destroys old red blood cells.

4. It helps you digest carbohydrates by producing enzymes.

Correct Answer: 2

Rationale 1: The gallbladder does have an important function within the body.

Rationale 2: The gallbladder is used to store bile that is produced in the liver, until the bile is needed to help digest fats.

Rationale 3: The spleen destroys red blood cells.

Rationale 4: The pancreas helps the body digest carbohydrates.

Global Rationale: The gallbladder is used to store bile. It is a thin-walled sac that is nestled in a shallow depression on the ventral surface of the liver. The gallbladder releases stored bile into the duodenum when stimulated and thus promotes the emulsification of fats. The main functions of the gallbladder are storing of bile and assisting in the digestion of fats. The spleen destroys red blood cells. The pancreas helps the body digest carbohydrates.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen

Question 6

Type: MCMA

The nurse is palpating the left upper quadrant of a clients abdomen. Which of the following organs may be assessed during this portion of the assessment?

Standard Text: Select all that apply.

1. Liver

2. Gallbladder

3. Appendix

4. Spleen

5. Stomach

Correct Answer: 4,5

Rationale 1: Liver. The liver is located in the right upper quadrant.

Rationale 2: Gallbladder. The gallbladder is located in the right upper quadrant.

Rationale 3: Appendix. The appendix is located in the right lower quadrant.

Rationale 4: Spleen. The spleen is located in the left upper quadrant.

Rationale 5: Stomach. The stomach is located in the left upper quadrant.

Global Rationale: The spleen is located in the left upper quadrant. The stomach is located in the left upper quadrant. The liver is located in the right upper quadrant. The gallbladder is located in the right upper quadrant. The appendix is located in the right lower quadrant.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.1: Recall the anatomy and physiology of the abdomen.

Question 7

Type: MCMA

The nurse is mapping the clients abdomen into four quadrants. Which of the following landmarks would the nurse use to perform this assessment?

Standard Text: Select all that apply.

1. Umbilicus

2. Midclavicular lines

3. Xiphoid process

4. Lower border of the right ribs

5. Iliac crests

Correct Answer: 1,3

Rationale 1: Umbilicus. To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal line perpendicular to the first line.

Rationale 2: Midclavicular lines. The midclavicular lines are not used to map the clients abdomen into four quadrants.

Rationale 3: Xiphoid process. To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal line perpendicular to the first line.

Rationale 4: Lower border of the right ribs. The lower border of the right ribs is not used to map the clients abdomen into four quadrants.

Rationale 5: Iliac crests. The iliac crests are not used to map the clients abdomen into four quadrants.

Global Rationale: To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal line perpendicular to the first line. The midclavicular lines are not used to map the clients abdomen into four quadrants. The lower border of the right ribs is not used to map the clients abdomen into four quadrants. The iliac crests are not used to map the clients abdomen into four quadrants.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.2: Identify landmarks that guide assessment of the abdomen.

Question 8

Type: MCSA

The nurse is performing a focused interview with a 79-year-old client. Which of the following statements by the client is unexpected?

1. I have been having loose stools every day for the last 3 years.

2. I know I just dont drink as much water as I should.

3. My belly seems softer and flabbier as I get older.

4. My mouth is always dry.

Correct Answer: 1

Rationale 1: Older clients tend to experience constipation as a result of changes in their digestive tracts. Loose stools are an unexpected finding in the older client.

Rationale 2: Older clients do not tend to drink as much water as they should to avoid frequent urination.

Rationale 3: The older clients abdomen tends to be softer and more relaxed than in the younger adult.

Rationale 4: The older clients saliva production is decreased resulting in a dry mouth.

Global Rationale: Older clients tend to experience constipation as a result of changes in their digestive tracts. Loose stools are an unexpected finding in the older client. Older clients do not tend to drink as much water as they should to avoid frequent urination. The older clients abdomen tends to be softer and more relaxed than in the younger adult. The older clients saliva production is decreased resulting in a dry mouth.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.3: Develop questions to be used when completing the focused interview.

Question 9

Type: MCMA

The student nurse is preparing to examine a client who is complaining of left lower quadrant abdominal pain. The experienced nurse is observing the student nurses abdominal assessment. Which of the following statements by the student nurse would indicate that the student nurse requires further education?

Standard Text: Select all that apply.

1. It is a little cool in our examination room; may I turn up the thermostat?

2. Ive been told you are experiencing some pain in the lower left area of your abdomen. I will examine that area first.

3. I am going to stand on your left side so I can feel your liver better.

4. Im going to place this drape over you so you dont feel too exposed during this examination.

5. I am going to place this pillow behind your head and this pillow under your knees.

Correct Answer: 2,3

Rationale 1: It is a little cool in our examination room; may I turn up the thermostat? The nurse should provide an environment that is warm and comfortable.

Rationale 2: Ive been told you are experiencing some pain in the lower left area of your abdomen. I will examine that area first. When a client is experiencing abdominal pain, the nurse should examine that area last.

Rationale 3: I am going to stand on your left side so I can feel your liver better. Stand on the right side of the client, because the liver and the right kidney are in the right side of the abdomen.

Rationale 4: Im going to place this drape over you so you dont feel too exposed during this examination. Maintain the dignity of the client through appropriate draping techniques.

Rationale 5: I am going to place this pillow behind your head and this pillow under your knees. The client should be in a supine position with a small pillow placed beneath the head and knees.

Global Rationale: When a client is experiencing abdominal pain, the nurse should examine that area last. Stand on the right side of the client, because the liver and the right kidney are in the right side of the abdomen. The nurse should provide an environment that is warm and comfortable. Maintain the dignity of the client through appropriate draping techniques. The client should be in a supine position with a small pillow placed beneath the head and knees.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.4: Explain client preparation for assessment of the abdomen.

Question 10

Type: MCMA

The nurse is performing an abdominal assessment on a client. During the focused interview, the client stated that he had been experiencing some abdominal pain. As the nurse assesses the client, which of the following behaviors indicates that the client may be experiencing pain or anxiety during the examination?

Standard Text: Select all that apply.

1. The clients respiratory rate is 26 per minute.

2. The client moves away from the nurses hands.

3. The client grimaces.

4. The client pulls his knees toward his stomach.

5. The client coughs loudly.

Correct Answer: 1,2,3,4

Rationale 1: The clients respiratory rate is 26 per minute. If the clients respiratory rate increases during the examination, it can indicate that the client is experiencing pain or anxiety.

Rationale 2: The client moves away from the nurses hands. The client may move away from the nurse during the examination if the client is experiencing pain.

Rationale 3: The client grimaces. Grimacing is a facial expression that can indicate that the client is experiencing pain during the assessment.

Rationale 4: The client pulls his knees toward his stomach. The client who exhibits guarding behavior is most likely experiencing pain.

Rationale 5: The client coughs loudly. The client who coughs loudly is not necessarily experiencing pain. This is not a typical expression of pain or anxiety.

Global Rationale: If the clients respiratory rate increases during the examination, it may indicate that the client is experiencing pain or anxiety. The client may move away from the nurse during the examination if the client is experiencing pain. Grimacing is a facial expression that can indicate that the client is experiencing pain during the assessment. The client who exhibits guarding behavior is most likely experiencing pain. The client who coughs loudly is not necessarily experiencing pain. This is not a typical expression of pain or anxiety.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.4: Explain client preparation for assessment of the abdomen.

Question 11

Type: MCSA

The client was recently admitted to the hospital with left lower quadrant pain. The client states, It feels like my belly is cramping. Guarding is noted during the abdominal examination. During the focused interview, the client admitted to experiencing a significant amount of occupational stress. The nurse reviews the information included in the chart above and determines that the client has developed a specific condition. Which of the following statements by the client is most consistent with this condition?

1. I get home so late at night, but Ive got to stop lying down right after dinner.

2. I drink a whole pot of coffee every day.

3. I drink 912 beers after I get home from work, every day.

4. We have been growing green beans in our garden and I think I ate too many the other day.

Correct Answer: 4

Rationale 1: Lying down after meals is often associated with gastroesophageal reflux disorder.

Rationale 2: Caffeine intake is associated with irritable bowel syndrome.

Rationale 3: Drinking alcohol is associated with irritable bowel syndrome and pancreatitis.

Rationale 4: This client is most likely experiencing diverticulitis. The clients white blood cell count, temperature, and blood pressure are elevated as a result of the infection. High-fiber food intake can be a precipitating factor.

Global Rationale: This client most likely is experiencing diverticulitis. The clients white blood cell count, temperature, and blood pressure are elevated as a result of the infection. High-fiber food intake can be a precipitating factor. Lying down after meals is often associated with gastroesophageal reflux disorder. Caffeine intake is associated with irritable bowel syndrome. Drinking alcohol is associated with irritable bowel syndrome and pancreatitis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 12

Type: MCSA

The nurse is performing an abdominal assessment on a client. While the nurse is palpating the lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client complains of a sharp pain located in the right upper quadrant. In which of the following ways would the nurse accurately document this finding?

1. Positive Blumbergs sign

2. Presence of pain at McBurneys point

3. Positive Murphys sign

4. Positive Psoas sign

Correct Answer: 3

Rationale 1: Blumbergs sign can be elicited when the nurse presses on an area of the abdomen. If the client complains of pain as the nurse pulls back and releases the compressed area, the client has a positive Blumbergs sign.

Rationale 2: Pain at McBurneys point is associated with appendicitis. This area is located in the right lower quadrant of the clients abdomen.

Rationale 3: Murphys sign can be elicited when the client takes a deep breath and holds it while the nurse presses into the right upper quadrant. The nurse is pressing against the gallbladder. Normally, the client will not complain of pain.

Rationale 4: With the client in a supine position, the nurse places her left hand just above the level of the clients right knee. The client is requested to raise the leg to meet the nurses hand. Flexion of the hip causes contraction of the psoas muscle and indicates that the client is experiencing peritoneal inflammation, or appendicitis.

Global Rationale: Pain with palpation of the liver is indicative of cholecystitis and is noted as a positive Murphys sign. The examination should be halted. Blumbergs sign is sharp pain occurring with the release of a compressed area and is present when the client has peritoneal irritation. Pain at McBurneys point in the right lower quadrant is associated with appendicitis. Pain that is elicited while flexing the hip is indicative of psoas muscle irritation and is associated with peritoneal inflammation or appendicitis.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 13

Type: MCSA

The nurse is assessing the clients abdomen and notes dullness when percussing over the left lower quadrant. Which of the following questions is most appropriate for the nurse to ask the client at this time?

1. How much alcohol do you drink?

2. Do you have pain after eating?

3. When was your last bowel movement?

4. Have you ever had splenomegaly?

Correct Answer: 3

Rationale 1: Alcohol can place the client at risk for hepatomegaly and inflammation of the liver.

Rationale 2: Pain after eating may indicate that some sort of upper gastrointestinal problem has developed.

Rationale 3: Stool in the distal portion of the clients colon can produce dullness upon percussion of the left lower quadrant.

Rationale 4: Splenomegaly would produce dullness while percussing the left upper quadrant.

Global Rationale: Percussion over the abdomen produces tympany, and dullness is heard over the solid organs such as the liver and spleen. Dullness may also indicate an enlarged uterus, distended urinary bladder or ascites. Dullness in the left lower quadrant may also indicate the presence of stool in the colon. Significant alcohol consumption may be associated with possible liver enlargement. The nurse would be able to percuss the liver in the right upper quadrant. Pain after eating is more likely to be associated with an upper gastrointestinal problem. Splenomegaly is associated with dullness while percussing the clients left upper quadrant.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 14

Type: MCMA

The nurse is completing discharge instructions for a client admitted with esophagitis. Which of the following statements by the client indicate that the client requires further education?

Standard Text: Select all that apply.

1. Im going to talk to my doctor about a nicotine patch.

2. I can do all of this stuff youre talking about as long as I dont have to give up my beer.

3. I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle.

4. The root of this problem is that I just sleep too much.

5. I told my wife to stop making serving me all of those vegetables.

Correct Answer: 2,4,5

Rationale 1: Im going to talk to my doctor about a nicotine patch. Smoking cigarettes is associated with an increased risk for developing esophagitis.

Rationale 2: I can do all of this stuff youre talking about as long as I dont have to give up my beer. Alcohol can increase the clients risk for developing esophagitis.

Rationale 3: I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle. Eating foods that are either too hot or too cold can be irritating to the tissue and can result in esophagitis.

Rationale 4: The root of this problem is that I just sleep too much. Sleeping too much is not associated with the development of esophagitis.

Rationale 5: I told my wife to stop making serving me all of those vegetables. Eating vegetables is not associated with the development of esophagitis.

Global Rationale: Alcohol can exacerbate and is an established risk factor for the development of esophagitis. Sleeping too much is not associated with the development of esohagitis. Eating vegetables is not associated with the development of esophagitis. Smoking cigarettes is associated with an increased risk for developing esophagitis. Eating foods that are either too hot or too cold can be irritating to the tissue and can result in esophagitis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 15

Type: MCSA

The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back. The client states, This has been happening more often after I eat rich, high-fat foods. The nurse would suspect which of the following?

1. Cholecystitis

2. Duodenal ulcer

3. Gastritis

4. Pancreatitis

Correct Answer: 1

Rationale 1: Right upper quadrant pain that radiates to the right scapula is characteristic of cholecystitis. The pain usually occurs after the client eats a fatty meal.

Rationale 2: Duodenal ulcers cause aching, gnawing, epigastric pain. This is associated with stress and NSAID use.

Rationale 3: Gastritis causes epigastric pain. It is associated with NSAID use, alcohol abuse, stress, infection, H. pylori infection, and/ or autoimmune responses.

Rationale 4: Pancreatitis produces upper abdominal, knifelike, deep epigastric or umbilical area pain. It is associated with alcohol abuse, use of acetaminophen, and infection.

Global Rationale: Right upper quadrant pain that radiates to the right scapula is characteristic of cholecystitis. The pain usually occurs after the client eats a fatty meal. Duodenal ulcers cause aching, gnawing, epigastric pain. It is associated with stress and NSAID use. Gastritis causes epigastric pain. It is associated with NSAID use, alcohol abuse, stress, infection, H. pylori infection, and autoimmune responses. Pancreatitis produces upper abdominal, knifelike, deep epigastric or umbilical area pain. It is associated with alcohol abuse, use of acetaminophen, and infection.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 16

Type: MCSA

The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse notes that the liver span is approximately 9 centimeters. Which of the following ways is an appropriate way to document this finding?

1. Hepatomegaly

2. A normal finding

3. Related to recent diagnosis of chronic bronchitis

4. Presence of ascites

Correct Answer: 2

Rationale 1: Hepatomegaly would be associated with a liver span greater than 10 centimeters.

Rationale 2: This is a normal finding.

Rationale 3: The client with chronic bronchitis may have a liver that is displaced downward within the abdomen.

Rationale 4: The client with ascites may have a liver that is displaced upward within the abdomen.

Global Rationale: The liver span is the distance between the lower and upper border of the liver. It should be approximately 5 to 10 centimeters (2 to 4 inches). The liver in this situation is not enlarged, and it would be inappropriate for the nurse to determine that client has an enlarged liver (hepatomegaly). The client with chronic bronchitis may have a liver that is displaced downward within the abdomen. The client with ascites may have a liver that is displaced upward within the abdomen.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 17

Type: MCSA

The nurse is completing an abdominal assessment and is percussing over the left side of the upper portion of the clients abdomen over the area of the stomach. The client states, I havent had my breakfast, yet. The nurse would expect to find which of the following during this part of the examination?

1. Dullness

2. Flatness

3. Tympany

4. Hyperesonance

Correct Answer: 3

Rationale 1: Dullness suggests a mass within the stomach. It is a short high-pitched sound heard over solid organs, masses, or fluid-filled structures.

Rationale 2: Flat sounds are short and abrupt. They are heard over bone or muscle.

Rationale 3: Tympany is the normal sound that can be heard when an air-filled structure is percussed.

Rationale 4: Hyperesonance is a hollow sound that is louder than tympany. Hyperresonance is louder than tympany and is heard over air-filled or distended intestines.

Global Rationale: Tympany is a loud, drum-like sound heard over structures filled with air, such as the stomach or air in the intestines. Dullness is a soft to moderate thud-like sound heard over solid organs such as the liver. If heard over the stomach, dullness suggests a stomach mass and also may be heard after a large meal. Flatness is a soft, flat sound heard over muscle or bone.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 18

Type: MCSA

The nurse is documenting the findings of an abdominal assessment on a client and documents the following information, pain noted during palpation at McBurneys point. In which of the following ways did the nurse elicit this response?

1. The nurse lightly palpated the around the clients umbilicus.

2. The nurse pressed into the clients abdomen and then pulled his hand back quickly.

3. The nurse palpated over the clients spleen.

4. The nurse palpated the area between the clients ileum and umbilicus in the clients right lower quadrant.

Correct Answer: 4

Rationale 1: The nurse should be able to lightly palpate around the umbilicus without any complaints of pain by the client.

Rationale 2: This procedure is used to elicit the Blumbergs sign.

Rationale 3: Palpation over the clients spleen may be used to determine if the client has splenomegaly.

Rationale 4: The nurse can palpate over McBurneys point to determine if the client has developed appendicitis.

Global Rationale: McBurneys point is located 2.5 to 5.1 centimeters above the anterosuperior iliac spine, on a line between the ileum and the umbilicus. When the client experiences pain at this site with palpation it is referred to as a positive Rovsings sign, which is suggestive of peritoneal irritation that is most frequently associated with appendicitis. Pain with palpation over the umbilicus may indicate an infectious process such as diverticulitis. A hernia may be palpated or visualized during the nurses inspection of the clients abdomen. Pain as an area is compressed and then is allowed to decompress is known as a positive Blumbergs sign. This sign occurs in clients with peritoneal irritation. Normally, the client should feel pressure but no pain as the nurse palpates the clients spleen.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 19

Type: MCSA

The client states, No one will let me eat or drink anything until after my test and its been 9 hours since I last ate anything! While auscultating the clients abdomen the nurse hears frequent bowel sounds. In which of the following ways should the nurse accurately document this finding?

1. Borborygmi present

2. Hypoactive bowel sounds present

3. Bruit present

4. Friction rub present

Correct Answer: 1

Rationale 1: Borborygmi are hyperactive bowel sounds.

Rationale 2: Hypoactive bowel sounds are not normally auscultated in clients who are merely hungry. They are more often auscultated in clients who have developed a bowel obstruction or who have had a major abdominal surgery.

Rationale 3: Bruits can be auscultated over blood vessels.

Rationale 4: Friction rubs are associated with the rubbing together of abdominal organs or organs that may be rubbing on the peritoneum.

Global Rationale: Normal bowel sounds occur every 5 to 15 seconds. Borborygmi are hyperactive bowel sounds that are most often auscultated in clients who have not eaten recently. Hypoactive bowel sounds are most often auscultated in clients who have had abdominal surgery or who have a bowel obstruction. A bruit is a pulsing, blowing sound that can be auscultated over arteries. A friction rub is a rough, grating sound caused by the rubbing together of organs or an organ rubbing on the peritoneum.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 20

Type: MCMA

The nurse is assessing a client in the Emergency Department with complaints of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. The nurse accurately suspects that which of the following conditions or problems may be occurring?

Standard Text: Select all that apply.

1. Constipation

2. Appendicitis

3. Cholecystitis

4. Small bowel obstruction

5. Peritonitis

Correct Answer: 2,5

Rationale 1: Constipation. Constipation is not typically associated with a positive psoas sign.

Rationale 2: Appendicitis. A positive psoas sign is indicative of irritation of the psoas muscle and is associated with appendicitis.

Rationale 3: Cholecystitis. The client with cholecystitis may exhibit a positive Murphys sign.

Rationale 4: Small bowel obstruction. The client with a small bowel obstruction may exhibit abnormal bowel sounds.

Rationale 5: Peritonitis. A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation.

Global Rationale: A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation or appendicitis. Constipation is not typically associated with a positive psoas sign. The client with cholecystitis may exhibit a positive Murphys sign. The client with a small bowel obstruction may exhibit abnormal bowel sounds.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 21

Type: MCSA

The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the stethoscope. The nurse hears a soft, continuous humming sound. The nurse suspects that dysfunction of which of the following organs ultimately may have resulted in the production of this sound?

1. Stomach

2. Spleen

3. Pancreas

4. Liver

Correct Answer: 4

Rationale 1: Dysfunction in the clients stomach did not result in this type of sound.

Rationale 2: Dysfunction in the clients spleen most likely did not result in this type of sound.

Rationale 3: Dysfunction in the clients pancreas did not result in this type of sound.

Rationale 4: The nurse is hearing an abnormal abdominal sound called a venous hum, which is indicative of portal hypertension. Portal hypertension is the result of liver congestion.

Global Rationale: The nurse is hearing an abnormal abdominal sound called a venous hum, which is indicative of portal hypertension. Portal hypertension is the result of liver congestion. Dysfunction in the clients stomach did not result in this type of sound. Dysfunction in the clients spleen most likely did not result in this type of sound. Dysfunction in the clients pancreas did not result in this type of sound.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 22

Type: MCMA

The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. As the nurse inspected the clients abdomen, the nurse suspected that the client had developed ascites. The nurse would perform which of the following nursing interventions as a result of this finding?

Standard Text: Select all that apply.

1. Obtain stool specimen for occult blood.

2. Measure the clients abdominal girth.

3. Obtain stool specimen for culture and sensitivity.

4. Bilateral leg measurements.

5. Percuss the abdomen at midline.

Correct Answer: 2,5

Rationale 1: Obtain stool specimen for occult blood. The nurse would not necessarily suspect that the client had occult blood in the stool.

Rationale 2: Measure the clients abdominal girth. When ascites is suspected, the abdominal girth should be measured to obtain a baseline for further evaluation.

Rationale 3: Obtain stool specimen for culture and sensitivity. The nurse does not need to send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed that the client had an infection within the gastrointestinal tract.

Rationale 4: Bilateral leg measurements. The nurse does not necessarily need to measure the circumferences of the clients legs for edema.

Rationale 5: Percuss the abdomen at midline. The nurse would need to assess the clients abdomen for tympany during percussion. This is a sign of ascites.

Global Rationale: The nurse should measure the clients abdominal girth to obtain baseline information for further comparisons. The nurse should percuss the abdomen at midline for tympany because this is a sign of ascites. The nurse would not necessarily suspect that the client had occult blood in the stool. The nurse does not need to send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed that the client had an infection within the gastrointestinal tract. The nurse does not necessarily need to measure the circumferences of the clients legs for edema.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 23

Type: FIB

The clients ideal body weight is 125 pounds. The nurse is calculating the clients weight in order to determine if the client is obese. The client weighs 155.5 kilograms. Calculate the clients weight in pounds. Round to the nearest whole number.
______ pounds

Standard Text:

Correct Answer: 342 pounds

Rationale: The client weighs more than 100 pounds over the ideal body weight. There are 2.2 pounds in 1 kilogram. The clients weight in pounds is 342.1 pounds and when rounded to the nearest whole number, the clients weight is 342 pounds.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.5: Differentiate normal from abnormal findings in physical assessment of the abdomen.

Question 24

Type: MCSA

The nurse is performing an abdominal assessment on an infant. The nurse notes that the umbilicus is bulging and has been displaced slightly to the left of midline. The nurse would suspect that the infant has developed which of the following conditions?

1. Infection

2. Umbilical hernia

3. Ventral hernia

4. Hiatal hernia

Correct Answer: 2

Rationale 1: This is not a sign of an infection.

Rationale 2: This is a normal finding in an infant. A protruding or displaced umbilicus is a normal variation in pregnant females. An umbilical hernia occurs at the umbilicus and allows the intestines or other abdominal structures to protrude through the abdominus rectus muscle and come closer to the skin.

Rationale 3: Ventral hernias occur in previous incisional sites.

Rationale 4: A hiatal hernia is due to a weakening in the diaphragm that allows a portion of the stomach and the esophagus to move into the thoracic cavity. This type of hernia is more commonly found in adults than in children.

Global Rationale: An umbilical hernia occurs at the umbilicus and allows the intestines or other abdominal structures to protrude through the abdominus rectus muscle and come closer to the skin. This is not a normal finding in an infant. A protruding or displaced umbilicus is a normal variation in pregnant females. Ventral hernias occur in previous incisional sites. A hiatal hernia is due to a weakening in the diaphragm that allows a portion of the stomach and the esophagus to move into the thoracic cavity. This type of hernia is more commonly found in adults than in children.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 25

Type: SEQ

The nurse is performing an abdominal assessment on the client. Rank the following steps of assessment in the order that they should be performed.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Percuss the abdomen.

Choice 2. Visualize the quadrants of the abdomen.

Choice 3. Palpate the abdomen.

Choice 4. Auscultate the abdomen.

Choice 5. Encourage the client to void.

Correct Answer: 5,2,4,1,3

Rationale 1: The first step is for the nurse to encourage the client to void prior to the abdominal assessment.

Rationale 2: The second step is for the nurse to visualize the quadrants of the clients abdomen.

Rationale 3: The third step is for the nurse to auscultate the abdomen.

Rationale 4: The fourth step is for the nurse to percuss the abdomen.

Rationale 5: The fifth step is for the nurse to palpate the abdomen.

Global Rationale: The client should be encouraged to void prior to the abdominal assessment. Physical assessment of the abdomen requires the use of inspection, auscultation, percussion, and palpation. This order differs from that of physical assessment of other systems. The nurse should remember to auscultate after inspection. Delaying percussion and palpation prevents disturbance of the normal bowel sounds. During each of the procedures the nurse is gathering data related to problems with underlying abdominal organs and structures.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.7: Describe the variation in techniques required for assessment of the abdomen.

Question 26

Type: MCSA

The nurse is caring for a client with hepatitis A virus. The client requests information about how the virus is transmitted. Which of the following statements by the nurse is the best response?

1. This virus is transmitted by sexual contact with someone who already has been infected with this virus.

2. Most likely, you ate something that was contaminated with the virus.

3. It is spread by blood transfusions.

4. Have you ever injected an illegal drug?

Correct Answer: 2

Rationale 1: Sexual contact with someone who is infected with a specific virus resulting in hepatitis is most closely associated with developing hepatitis B or D.

Rationale 2: Eating food that is contaminated with hepatitis A virus may result in the client developing clinical manifestations associated with hepatitis A virus.

Rationale 3: Blood product transfusions can result in the transmission of hepatitis B, C, or D viruses.

Rationale 4: Injecting illegal drugs can result in the transmission of hepatitis B, C, or D viruses.

Global Rationale: Educating clients about hepatitis A, B, and C viruses is included in the Healthy People 2020 objectives. Education about the viruses can help reduce transmission. Hepatitis A virus is transmitted through enteric routes and is usually the result of eating food that was contaminated with the virus. Hepatitis B virus is transmitted parenterally, sexually, or perinatally. Hepatitis C virus is transmitted via blood and blood products, parenterally, and through other unknown factors. Hepatitis B, C, and D viruses can be transmitted parentally and the client may be infected while injecting illegal drugs.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.8: Discuss the objectives in Healthy People 2020 as they relate to issues of the abdomen and gastrointestinal system.

Question 27

Type: MCSA

The pediatric nurse is preparing an educational presentation for parents of school-aged children regarding hepatitis. The nurse wishes to focus on the most common type that occurs in children. Which of the following types of hepatitis viruses would the nurse choose to focus on during this presentation?

1. Hepatitis A virus

2. Hepatitis B virus

3. Hepatitis C virus

4. Hepatitis D virus

Correct Answer: 1

Rationale 1: Hepatitis A virus is the most common type of virus resulting in hepatitis that develops in children.

Rationale 2: Hepatitis B virus is transmitted parenterally, sexually, or perinatally.

Rationale 3: Hepatitis C virus is transmitted through blood and blood products, parenterally, and through unknown ways.

Rationale 4: Hepatitis D virus is transmitted parenterally, sexually, and perinatally.

Global Rationale: Hepatitis A occurs most frequently in children and young adults. Hepatitis B, C, and D virus transmission seems unrelated to specific age groups and is most closely associated with specific risk factors or behaviors.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.8: Discuss the objectives in Healthy People 2020 as they relate to issues of the abdomen and gastrointestinal system.

Question 28

Type: MCMA

The student nurses are preparing educational presentations regarding the Healthy People 2020 objectives. The nursing instructor is reviewing the topics of their presentations. Which of the following topics are appropriate and related to the objectives?

Standard Text: Select all that apply.

1. Educate pregnant women regarding the importance of small, more frequent dry meals throughout the day to reduce nausea and vomiting.

2. Educate Asian men about the importance of avoiding alcohol because this is a population that is prone to alcohol abuse.

3. Educate people who are anticipating traveling to India, Asia, Africa, or Central America about ways to reduce their risk of becoming infected with hepatitis E virus.

4. Educate immunocompromised populations and those caring for them about the importance of safe food handling.

5. Educate people about the relationship between regular, thorough oral hygiene practices and good nutrition.

Correct Answer: 1,3,4,5

Rationale 1: Educate pregnant women regarding the importance of small, more frequent dry meals throughout the day to reduce nausea and vomiting. Pregnant women who eat smaller, dry meals throughout the day are less likely to experience nausea and vomiting than women who eat fewer, larger meals during the day.

Rationale 2: Educate Asian men about the importance of avoiding alcohol because this is a population that is prone to alcohol abuse. Caucasian and Hispanic populations are more prone to alcohol abuse than Asians.

Rationale 3: Educate people who are anticipating traveling to India, Asia, Africa, or Central America about ways to reduce their risk of becoming infected with hepatitis E virus. People who travel to Indian, Asia, Africa, or Central America are more likely to become infected with hepatitis E virus.

Rationale 4: Educate immunocompromised populations and those caring for them about the importance of safe food handling. Immunocompromised clients are more prone to developing foodborne illnesses. Safe food handling when preparing food for these clients is very important.

Rationale 5: Educate people about the relationship between regular, thorough oral hygiene practices and good nutrition. Poor oral hygiene is associated with malnutrition.

Global Rationale: Pregnant women who eat smaller, dry meals throughout the day are less likely to experience nausea and vomiting than women who eat fewer, larger meals during the day. People who travel to Indian, Asia, Africa, or Central America are more likely to become infected with hepatitis E virus. Immunocompromised clients are more prone to developing foodborne illnesses. Safe food handling when preparing food for these clients is very important. Poor oral hygiene is associated with malnutrition. Caucasian and Hispanic populations are more prone to alcohol abuse than Asians.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.8: Discuss the objectives in Healthy People 2020 as they relate to issues of the abdomen and gastrointestinal system.

Question 29

Type: MCMA

The nurse is interviewing a 79-year-old Hispanic client with complaints of recent weight loss, anorexia, and epigastric pain. The client reports recent use of mints for stomach upset. Which of the following interventions are appropriate?

Standard Text: Select all that apply.

1. Schedule the client for an endoscopy as ordered.

2. Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider.

3. Educate the client regarding Helicobacter pylori infections.

4. Discuss the importance of using over-the-counter aspirin for mild pain relief.

5. Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer.

Correct Answer: 1,2,3

Rationale 1: Schedule the client for an endoscopy as ordered. The client should be scheduled for an endoscopy as ordered by the healthcare provider. This is a common diagnostic test used for clients with suspected peptic ulcers.

Rationale 2: Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider. The client should take antacids after meals and at bedtime.

Rationale 3: Educate the client regarding Helicobacter pylori infections. The client should be educated about the most common cause of peptic ulcers, which is an infection due to Helicobacter pylori (H. pylori). H. pylori is a bacteria that results in an infection that causes more than 90% of peptic ulcers. It infects almost two thirds of the worlds population and is more prevalent in the elderly, African Americans, Hispanics, and those in lower socioeconomic groups.

Rationale 4: Discuss the importance of using over-the-counter aspirin for mild pain relief. The client should avoid aspirin products because they can make the symptoms worse.

Rationale 5: Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer. The client can avoid spicy foods but not because this is the most common cause of peptic ulcers. The spicy foods may aggravate the clients condition. In the past, it was believed that ulcers were caused by stress or eating too much acidic food. Now it is known that this is not true.

Global Rationale: The client should be scheduled for an endoscopy as ordered by the healthcare provider. This is a common diagnostic test used for clients with suspected peptic ulcers. The client should take antacids after meals and at bedtime. The client should be educated about the most common cause of peptic ulcers, which is an infection due to Helicobacter pylori (H. pylori). H. pylori is a bacteria that results in an infection that causes more than 90% of peptic ulcers. It infects almost two thirds of the worlds population and is more prevalent in the elderly, African Americans, Hispanics, and those in lower socioeconomic groups. The client should avoid aspirin products because they can make the symptoms worse. The client can avoid spicy foods but not because this is the most common cause of peptic ulcers. The spicy foods may aggravate the clients condition. In the past, it was believed that ulcers were caused by stress or eating too much acidic food. Now it is known that this is not true.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.9: Apply critical thinking in selected simulations related to assessment of the abdomen.

Question 30

Type: MCMA

The client is 14 years old and is visiting the healthcare providers office with abdominal pain. The client states, The pain is sort of all over my belly. I cant really find one place that hurts more than another area. Based on the nurses understanding about disorders of abdomen and associated symptomatology, the nurse will expect to discover that which of the following nursing diagnoses can most likely be applied to this clients plan of care?

Standard Text: Select all that apply.

1. Acute pain

2. Hypothermia

3. Diarrhea

4. Altered urinary elimination

5. Altered nutrition, less than body requirements

Correct Answer: 1,3,5

Rationale 1: Acute pain. The client is currently experiencing diffuse acute pain and this is a common complaint for the client with ulcerative colitis.

Rationale 2: Hypothermia. It would be unusual for the client with ulcerative colitis to complain of hypothermia or have a lowered body temperature.

Rationale 3: Diarrhea. The client with ulcerative colitis will commonly experience diarrhea.

Rationale 4: Altered urinary elimination. The client with ulcerative colitis will not typically experience altered urinary elimination.

Rationale 5: Altered nutrition, less than body requirements. The client with ulcerative colitis may experience weight loss.

Global Rationale: This client is most likely experiencing clinical manifestations associated with ulcerative colitis. Ulcerative colitis is a recurrent inflammatory process causing ulcer formation in the lower portions of the large intestine and rectum. This condition is common in adolescents and young adults. The client is currently experiencing diffuse acute pain. The client will commonly complain of diarrhea. The client may experience weight loss. It would be unusual for the client to complain of hypothermia or have a lowered body temperature. The client with ulcerative colitis will not typically experience altered urinary elimination.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 19.9: Apply critical thinking in selected simulations related to assessment of the abdomen.

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