Question 1

The nurse is assessing a patient who is exhibiting pain in the right lower quadrant (RLQ).Based on this data,which diagnosis does the nurse suspect?&#10;A) Cholelithiasis&#10;B) Appendicitis&#10;C) Cholecystitis&#10;D) Pneumonia&#10;

Accepted Answer

Pain in the RLQ is a classic symptom of appendicitis. Cholelithiasis and cholecystitis usually present with pain in the upper right quadrant, while pneumonia may present with chest pain and shortness of breath.

Question 2

Which is the primary system that is assessed by the nurse during an abdominal assessment?&#10;A) Reproductive&#10;B) Urinary&#10;C) Digestive&#10;D) Respiratory&#10;

Accepted Answer

During an abdominal assessment, the primary system that is assessed by the nurse is the digestive system, as this is the system responsible for the digestion and absorption of nutrients from food. The nurse will assess for any abnormalities in bowel sounds, tenderness, masses, or distension, which can indicate problems with digestion and elimination. The reproductive, urinary, and respiratory systems may also be assessed during a comprehensive physical assessment, but they are not the primary focus of an abdominal assessment.

Question 3

Which structure,located in the right upper quadrant (RUQ)of the abdomen,is assessed by the nurse by palpation and percussion?&#10;A) Spleen&#10;B) Stomach&#10;C) Sigmoid&#10;D) Liver&#10;

Accepted Answer

The liver is located in the right upper quadrant of the abdomen, and is assessed by nurses by palpation and percussion. The spleen is located in the left upper quadrant, the stomach is in the left upper and central portions, and the sigmoid colon is in the left lower quadrant.

Question 4

Which action by the nurse is appropriate when determining if bowel sounds are absent during the patient assessment?&#10;A) Palpating the abdomen for two minutes&#10;B) Inspecting the abdomen for 30 seconds&#10;C) Percussing the abdomen for 60 seconds&#10;D) Auscultating the abdomen for five minutes&#10;

Accepted Answer

Auscultating the abdomen for five minutes is the appropriate action to determine if bowel sounds are absent. Bowel sounds may take up to five minutes to be heard in some patients, so it is important to listen for an adequate amount of time before determining if bowel sounds are absent. Palpating, inspecting, and percussing the abdomen do not provide information about bowel sounds.

Question 5

Which action by the nurse is appropriate when attempting to locate the spleen during the abdominal assessment?&#10;A) Percussing over the 9th to the 11th ribs at the midaxillary line&#10;B) Performing the scratch test&#10;C) Auscultating for venous hums&#10;D) Palpating for the apical pulse&#10;

Accepted Answer

Percussing over the 9th to the 11th ribs at the midaxillary line is the appropriate method for locating the spleen during an abdominal assessment. The spleen is located in the left upper quadrant of the abdomen and may be enlarged in certain medical conditions, such as splenomegaly. Palpation may be used to further assess the size and texture of the spleen, but should only be performed by a healthcare provider with advanced training in this technique. The scratch test is used for assessing abdominal pain or discomfort and is not specific to locating the spleen. Auscultation for venous hums and palpation for the apical pulse are both unrelated to locating the spleen.

Question 6

Which is the normal liver span at the midclavicular line the nurse anticipates when conducting a gastrointestinal assessment?&#10;A) 3 to 6 cm&#10;B) 4 to 8 cm&#10;C) 6 to 12 cm&#10;D) 12 to 16 cm&#10;

Accepted Answer

The normal liver span at the midclavicular line is typically between 6 to 12 cm.

Question 7

Which bowel sound noted by the nurse during the gastrointestinal assessment indicates an early bowel obstruction?&#10;A) Hyperperistaltic&#10;B) Hypoperistaltic&#10;C) Absent&#10;D) Epigastric&#10;

Accepted Answer

Hyperperistaltic bowel sounds, also known as "high-pitched" or "tinkling" sounds, are often associated with early bowel obstruction as the intestines attempt to push contents past the obstruction.

Question 8

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?

A) Appendicitis
B) Bowel obstruction
C) Cirrhosis
D) Cholelithiasis

Accepted Answer

The absent bowel sounds and abdominal distension are classic symptoms of bowel obstruction. This occurs when there is a blockage in the intestinal tract and can cause pain and discomfort in the abdomen. Appendicitis, cirrhosis, and cholelithiasis may also cause abdominal pain, but they do not typically present with absent bowel sounds and abdominal distension.

Question 9

The patient reports left upper quadrant (LUQ)pain.Based on this data,which does the nurse suspect?&#10;A) Ruptured spleen&#10;B) Pneumonia&#10;C) Hepatitis&#10;D) Duodenal ulcer&#10;

Accepted Answer

Left upper quadrant (LUQ) pain is commonly associated with splenic pathology such as a ruptured spleen. Other potential causes include gastric ulcers, gastritis, pancreatitis, and colitis. However, among the choices given, a ruptured spleen is the most likely cause of LUQ pain.

Question 10

The nurse is assessing a patient who presents with weight loss.Which assessment question is most appropriate for this patient?&#10;A) &#34;How is your appetite?&#34;&#10;B) &#34;How frequent are your bowel movements?&#34;&#10;C) &#34;When was your last bowel movement?&#34;&#10;D) &#34;What color is your stool?&#34;&#10;

Accepted Answer

Asking about the patient's appetite is the most appropriate assessment question for a patient presenting with weight loss as it can help to determine if the patient is not eating enough or if there could be other underlying causes for the weight loss.

Question 11

Which sound would the nurse expect to elicit when percussing the liver?&#10;A) Resonance&#10;B) Hyperresonance&#10;C) Dullness&#10;D) Tympany&#10;

Accepted Answer

The answer of Which sound would the nurse expect to...

Question 12

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?&#10;A) GI bleeding&#10;B) Hepatic necrosis&#10;C) Diarrhea&#10;D) Hypoactive bowel sounds&#10;

Accepted Answer

The answer of The nurse is assessing a patient who...

Question 13

Which organ functions as a main site for metabolizing drugs and may become impaired with the aging process?&#10;A) Stomach&#10;B) Liver&#10;C) Spleen&#10;D) Large intestine&#10;

Accepted Answer

The answer of Which organ functions as a main site...

Question 14

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?&#10;A) Borborygmi&#10;B) Everted umbilicus&#10;C) Visible peristaltic waves&#10;D) Bluish tint around the umbilicus&#10;

Accepted Answer

The answer of An older adult patient is admitted to...

Question 15

Which structure is located in the left upper quadrant (LUQ)of the abdomen?&#10;A) Liver&#10;B) Spleen&#10;C) Appendix&#10;D) Sigmoid&#10;

Accepted Answer

The answer of Which structure is located in the left...

Question 16

Which structure is located in the right lower quadrant (RLQ)of the abdomen?&#10;A) Liver&#10;B) Stomach&#10;C) Cecum&#10;D) Sigmoid&#10;

Accepted Answer

The answer of Which structure is located in the right...

Question 17

The nurse notes a positive shifting dullness during abdominal percussion.Which diagnosis does this assessment data support?&#10;A) Ascites&#10;B) Liver enlargement&#10;C) Pancreatitis&#10;D) An abdominal mass&#10;

Accepted Answer

The answer of The nurse notes a positive shifting dullness...

Question 18

Which is the correct sequence for the abdominal exam?&#10;A) Inspection,palpation,percussion,and auscultation&#10;B) Inspection,percussion,palpation,and auscultation&#10;C) Inspection,auscultation,percussion,and palpation&#10;D) Inspection,auscultation,palpation,and percussion&#10;

Accepted Answer

The answer of Which is the correct sequence for the...

Question 19

Which structure of the gastrointestinal (GI)system is found in the right upper quadrant (RUQ)and is the primary site of absorption?&#10;A) Stomach&#10;B) Duodenum&#10;C) Sigmoid&#10;D) Large intestine&#10;

Accepted Answer

The answer of Which structure of the gastrointestinal (GI)system is...

Deck 55: Assessment of Gastrointestinal Function