Question 1

The nurse notes a positive Murphy sign during the physical assessment. Which does the nurse suspect based on this data?

Accepted Answer

A positive Murphy sign is indicative of cholecystitis, which is inflammation of the gallbladder. This sign is elicited by asking the patient to take a deep breath while the examiner's fingers are hooked under the rib cage at the right side, causing pain and a sharp catch in breath if the gallbladder is inflamed.

Question 2

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?

Accepted Answer

Acetaminophen overdose can lead to hepatic necrosis, which is a severe liver damage condition. The liver is the primary site affected by acetaminophen toxicity due to its role in drug metabolism.

Question 3

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?

Accepted Answer

This technique is used to assess for kidney tenderness or pain, which can indicate an infection or inflammation of the kidneys, such as pyelonephritis.

Question 4

Which structure is found in the midline of the abdomen?

Accepted Answer

The aorta is the major blood vessel that runs down the center of the abdomen, supplying oxygenated blood to the body.

Question 5

What factor explains the protruding abdomen of an infant?

Accepted Answer

Weak abdominal muscles are a primary reason for the protruding abdomen in infants, as their abdominal wall muscles are not yet fully developed and strong enough to tightly hold the abdominal contents, leading to a more pronounced belly.

Question 6

Which is a life threatening cause of abdominal pain?

Accepted Answer

Abdominal aortic aneurysm (AAA) is a life-threatening condition because if the aneurysm ruptures, it can lead to massive internal bleeding and potentially death if not treated immediately.

Question 7

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?

Accepted Answer

Absent bowel sounds and abdominal distension are classic signs of a bowel obstruction. Appendicitis, cirrhosis, and cholelithiasis have different primary symptoms.

Question 8

Which disease process is more likely to occur in the Jewish population?

Accepted Answer

Colon cancer, particularly hereditary nonpolyposis colorectal cancer (HNPCC) and familial adenomatous polyposis (FAP), has a higher prevalence in the Ashkenazi Jewish population due to specific genetic mutations.

Question 9

When taking the health history of a patient who presents with acute abdominal pain, which is the priority action by the nurse?

Accepted Answer

Assessing vital signs is a priority action when a patient presents with acute abdominal pain. It helps in determining the patient's hemodynamic status and can indicate the severity of the condition, guiding further assessment and interventions.

Question 10

Which structure of the gastrointestinal (GI) system is found in the right upper quadrant (RUQ) and is the primary site of absorption?

Accepted Answer

The duodenum, part of the small intestine, is located in the right upper quadrant (RUQ) and is the primary site for nutrient absorption in the gastrointestinal system.

Question 11

Which finding on the abdominal exam would indicate the need for further evaluation?

Accepted Answer

Spider angiomas on the abdomen can indicate liver disease, which requires further evaluation. Choices A, B, and C can be normal findings in the described scenarios.

Question 12

Which of the following changes to bowel sounds occurs during pregnancy?

Accepted Answer

During pregnancy, bowel sounds may become hypoactive due to the effects of progesterone, which slows down gastrointestinal motility.

Question 13

How long do you listen to each quadrant to determine that bowel sounds are absent?

Accepted Answer

To determine that bowel sounds are absent, you should listen to each quadrant for at least 5 minutes. This is because bowel sounds can be infrequent, and a shorter listening period might miss intermittent sounds.

Question 14

The patient is complaining of left upper quadrant (LUQ) pain. Based on this data which does the nurse suspect?

Accepted Answer

LUQ pain is often associated with issues related to the spleen, such as a ruptured spleen, because the spleen is located in the left upper quadrant of the abdomen.

Question 15

Which is the main site for metabolizing drugs which may become impaired with the aging process?

Accepted Answer

The liver is the primary site for drug metabolism. Its function can become impaired with aging, affecting the body's ability to process and eliminate medications.

Question 16

The nurse notes a positive shifting dullness. Which diagnosis does this assessment finding support?

Accepted Answer

A positive shifting dullness is a physical examination finding that suggests the presence of ascites, which is the accumulation of fluid in the peritoneal cavity. This test is performed by percussing the abdomen and noting a change in the percussion note as the patient shifts position, indicating the movement of fluid.

Question 17

Which is the correct sequence for the abdominal exam?

Accepted Answer

The correct sequence for the abdominal exam is inspection, auscultation, percussion, and palpation. This order is recommended to avoid altering bowel sounds before they are auscultated.

Question 18

Which gastrointestinal (GI) changes is not anticipated when assessing an older adult patient?

Accepted Answer

An increase in muscle mass is not typically anticipated when assessing an older adult patient. In fact, aging is often associated with a decrease in muscle mass, not an increase. Changes to dentation, painful mastication, and a decrease in liver function are all changes that can be anticipated with aging.

Question 19

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?

Accepted Answer

Anticholinergic agents can lead to decreased gastrointestinal motility, which can result in conditions like paralytic ileus, an obstruction of the intestine due to paralysis of the intestinal muscles. This is a known adverse reaction to anticholinergic drugs.

Question 20

The Rovsing's sign and iliopsoas muscle test are useful to determine the presence of which disease process?

Accepted Answer

Rovsing's sign and the iliopsoas muscle test are clinical maneuvers used to assess for appendicitis. Rovsing's sign involves pain in the right lower quadrant upon palpation of the left lower quadrant, suggesting appendicitis. The iliopsoas muscle test, where the patient experiences pain upon extension of the hip or resistance against hip flexion, also suggests irritation from an inflamed appendix.

Quiz 9: Assessing the Abdomen