Chapter 13: Abdomen and Gastrointestinal System Nursing School Test Banks

Chapter 13: Abdomen and Gastrointestinal System
Test Bank

MULTIPLE CHOICE

1. A patient tells the nurse, Ive been having pain in my belly for several days that gets worse after eating. Which datum from the symptom analysis is consistent with the nurses suspicion of peptic ulcer disease?
a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating.
b. Sharp midepigastric pain radiates to the jaw.
c. Intermittent cramping pain in the left lower quadrant is relieved by defecation.
d. Colicky pain is felt near the umbilicus with vomiting and constipation.
ANS: A

Feedback
A Gnawing epigastric pain that radiates to the back or shoulder and worsens after eating is a symptom that is consistent with peptic ulcer disease.
B Sharp midepigastric pain that radiates to the jaw is not a symptom of peptic ulcer disease.
C Intermittent cramping pain in the left lower quadrant relieved by defecation is a symptom of diverticular disease rather than peptic ulcer disease.
D Colicky pain felt near the umbilicus with vomiting and constipation is a symptom of an intestinal obstruction rather than peptic ulcer disease.
DIF: Cognitive Level: Apply REF: 268-269
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

2. During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis?
a. Have you noticed any swelling in your ankles or feet at the end of the day?
b. Have you noticed a change in the color of your urine or stools?
c. Have you vomited up any blood in the last 24 hours?
d. Have you experienced fever, chills, or sweating?
ANS: B

Feedback
A This question is related to fluid retention, which may be asked if the patient has renal or heart failure.
B Gallstones can obstruct the flow of bile to the gastrointestinal tract making urine darker and stools lighter in color.
C This question applies if the patient has peptic ulcer disease or esophageal varices.
D This question applies if the patient has gastroenteritis or a urinary tract infection.
DIF: Cognitive Level: Analyze REF: 268-269
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

3. A patient reports having frequent heartburn. Which question does the nurse ask in response to this information?
a. Has your abdomen been distended when you feel the heartburn?
b. What have you eaten in the last 24 hours?
c. Is there a history of heart disease in your family?
d. How long after eating do you have heartburn?
ANS: D

Feedback
A The question Has your abdomen been distended when you feel the heartburn? is not related to the heartburn. Distention usually is related to intestinal obstruction or liver disease.
B The question What have you eaten in the last 24 hours? relates more to gastroenteritis. Indigestion is usually caused by food eaten in the last meal rather than in the last 24 hours.
C The question Is there a history of heart disease in your family? points to myocardial ischemia. Although heartburn may be a symptom of myocardial ischemia, asking the patient about the family history is not relevant in this case.
D Asking How long after eating do you have heartburn? can aid in determining if the patient has gastroesophageal reflux disease or a hiatal hernia. Both are common disorders that cause indigestion a few hours after meals.
DIF: Cognitive Level: Apply REF: 268-270
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

4. A patient reports having abdominal distention. The nurse notices that the patients sclerae are yellow. What question is appropriate for the nurse to ask in response to this information?
a. Has there been a change in your usual pattern of urination?
b. Have you had any nausea or vomiting?
c. Has there been a change in your bowel habits?
d. Have you had indigestion or heartburn?
ANS: B

Feedback
A Has there been a change in your usual pattern of urination? is not a question related to the abdominal distention and jaundice.
B Have you had any nausea or vomiting? is an appropriate question because the nurse suspects the patient may have a liver disease based on the abdominal distention and jaundice. The nurse interprets the relationship with data gathered from the history and the observation.
C Has there been a change in your bowel habits? is a question that may be related to the abdominal distention, but not the jaundice.
D Have you had indigestion or heartburn? is not a question related to the abdominal distention and jaundice. It applies more to gastric disorders, such as gastroesophageal reflux disease or hiatal hernia.
DIF: Cognitive Level: Analyze REF: 269-270
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

5. A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information?
a. Has there been a change in your usual pattern of urination?
b. Did you have heartburn before the vomiting?
c. What did the vomitus look like?
d. Have you noticed a change in the color of your urine or stools?
ANS: C

Feedback
A Has there been a change in your usual pattern of urination? is not a question related to abdominal distention and vomiting.
B Have you noticed a change in the color of your urine or stools? is not a question related to abdominal distention and vomiting. It is related to elevated bilirubin from liver or gallbladder disease and is accompanied by jaundice.
C What did the vomitus look like? is an appropriate question because the characteristics of the vomitus may help determine its cause. Acute gastritis leads to vomiting of stomach contents, obstruction of the bile duct results in greenish-yellow vomitus, and an intestinal obstruction may cause a fecal odor to the vomitus.
D This is not a question related to the abdominal distention and vomiting. Heartburn applies more to gastric disorders, such as gastroesophageal reflux disease or hiatal hernia.
DIF: Cognitive Level: Apply REF: 268| 270
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

6. A patient reports a change in the usual pattern of urination. What question does the nurse ask to determine if incontinence is the reason for these symptoms?
a. Do you have the feeling that you cannot wait to urinate?
b. Are you urinating a large amount each time you go to the bathroom?
c. Has the color of your urine changed lately?
d. Have you noticed any swelling in your ankles at the end of the day?
ANS: A

Feedback
A Do you have the feeling that you cannot wait to urinate? is a question that asks about urgency, a symptom of incontinence.
B Are you urinating a large amount each time you go to the bathroom? is not a question related to incontinence. Usually patients with incontinence void frequently in small amounts.
C Has the color of your urine changed lately? is a question that is asked when the nurse suspects the patient has gallbladder or liver disease.
D Have you noticed any swelling in your ankles at the end of the day? is a question that relates to patients who have renal or heart disease.
DIF: Cognitive Level: Apply REF: 270-271
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

7. In assessing a patient with renal disease, the nurse palpates edema in both ankles and feet. Based on this finding, what question does the nurse ask the patient?
a. Have you had any pain in your abdomen?
b. Have you had an unexpected weight gain?
c. Have you noticed a change in the color of your skin?
d. Have you had any nausea or vomiting?
ANS: B

Feedback
A This question does not relate to renal disease. The pain experienced with renal disease is usually flank pain over the costovertebral angle.
B This question relating to weight gain and edema suggests fluid retention that occurs with renal or heart disease, particularly renal failure.
C This question does not relate to renal disease. It might relate to liver or gallbladder disease if the change in skin color was yellow, indicating jaundice.
D This question usually relates to disorders within the gastrointestinal tract itself and not renal disease.
DIF: Cognitive Level: Apply REF: 270-271
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

8. A patient reports having abdominal distention. The nurse observes that the patients sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patients abdomen?
a. Decreased bowel sounds in all quadrants
b. Glistening or taut skin of the abdomen
c. Bulge in the abdomen when coughing
d. Bruit around the umbilicus
ANS: B

Feedback
A Decreased bowel sounds in all quadrants may be present if the abdominal distention was from an intestinal obstruction, but the observation of jaundice suggests liver disease, which does not decrease bowel sounds.
B Glistening or taut skin of the abdomen is consistent with ascites that appear as abdominal distention. Jaundice and ascites suggest liver disease. There would also be an increase in abdominal girth.
C A bulge in the abdomen when coughing is a finding associated with abdominal or incisional hernias.
D Bruit around the umbilicus is a finding associated with an abdominal aortic aneurysm.
DIF: Cognitive Level: Analyze REF: 270
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

9. When inspecting a patients abdomen, which finding does the nurse note as normal?
a. Engorgement of veins around the umbilicus
b. Sudden bulge at the umbilicus when coughing
c. Visible peristalsis in all quadrants
d. Silver-white striae extending from the umbilicus
ANS: D

Feedback
A Engorgement of veins around the umbilicus is an abnormal finding.
B Sudden bulge at the umbilicus when coughing is an abnormal finding and may indicate a hernia.
C Visible peristalsis in all quadrants is an abnormal finding.
D Silver-white striae extending from the umbilicus is a normal finding, particularly in women who have been pregnant or in any adult who has lost weight after having an obese abdomen.
DIF: Cognitive Level: Understand REF: 272
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

10. When inspecting a patients abdomen, the nurse notes which finding as abnormal?
a. Protruding abdomen with skin that is lighter in color than the arms and legs
b. Marked rhythmic pulsation to the left of the midline
c. Faint, fine vascular network
d. Small shadows created by changes in contour
ANS: B

Feedback
A Obesity may cause a protruding abdomen and although obesity is not an indicator of health, it does not necessarily indicate a disease is present.
B Marked rhythmic pulsation to the left of the midline is an abnormal finding that may indicate an abdominal aortic aneurysm.
C A faint, fine vascular network is a normal finding. If the vessels were engorged, it would be an abnormal finding.
D Small shadows created by changes in contour are a normal finding and they are seen by using a light source to inspect the contour.
DIF: Cognitive Level: Understand REF: 272
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

11. On inspection of a female patients abdomen, the nurse asks the patient to raise her head without using her arms and notes a midline bulge. What is the appropriate response of the nurse at this time?
a. Ask the patient to cough to see if the bulge reappears.
b. Auscultate the patients abdomen for hypoactive bowel sounds.
c. Document this as a normal finding and continue the examination.
d. Perform light and deep palpation of the abdomen.
ANS: C

Feedback
A Ask the patient to cough to see if the bulge reappears. A bulge that appears with coughing is an abnormal finding revealed by the increase in intrathoracic pressure during the cough.
B Auscultating the patients abdomen for hypoactive bowel sounds is not indicated because the bulge is a normal finding.
C Document this as a normal finding and continue the examination. This is a normal finding on a patient
D Performing light and deep palpation of the abdomen are not indicated because the bulge is a normal finding.
DIF: Cognitive Level: Understand REF: 273
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

12. A nurse notices abdominal distention when inspecting a patients abdomen. What action does the nurse take next to gain further objective data?
a. Place a measuring tape around the superior iliac crests.
b. Assist the patient to turn on to the left side and then the right side.
c. Ask the patient to cough while lying supine.
d. Use the fingertips to sharply strike one side of the abdomen.
ANS: A

Feedback
A This is the procedure for measuring abdominal girth.
B This procedure is unnecessary. The distention will remain in a side-lying position.
C Having the patient cough is used to assess for bulges rather than distention.
D This is part of the procedure to test for a fluid wave, which is not indicated in this patient.
DIF: Cognitive Level: Understand REF: 273
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

13. A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next?
a. Palpate lightly for tenderness and muscle tone.
b. The tip of the middle finger of the dominant hand strikes the nail of the middle finger touching the skin of the abdomen.
c. Palpate deeply for masses or aortic pulsation.
d. Percuss for tones.
ANS: B

Feedback
A Palpating lightly for tenderness and muscle tone is performed after auscultation.
B Auscultation for bowel sounds occurs before palpating and percussing the abdomen.
C Palpating deeply for masses or aortic pulsation is performed after light palpation.
D Percussion for tones is performed after palpation.
DIF: Cognitive Level: Apply REF: 273
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

14. How does the nurse accurately assess bowel sounds?
a. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant.
b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant.
c. Press the bell of the stethoscope firmly against the abdomen in each quadrant.
d. Hold the bell of the stethoscope lightly against the abdomen in each quadrant.
ANS: B

Feedback
A Pressing the diaphragm of the stethoscope firmly against the abdomen in each quadrant is not the correct technique for listening to bowel sounds.
B Holding the diaphragm lightly against the abdomen in each quadrant is the correct technique for listening to bowel sounds.
C The bell is used to listen to vascular sounds of the abdomen, which are normally not heard.
D The bell is used to listen to vascular sounds of the abdomen, which are normally not heard.
DIF: Cognitive Level: Understand REF: 273
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

15. When auscultating a patients abdomen using the bell of the stethoscope, the nurse hears soft, low-pitched murmurs over the right and left upper midline. What do these sounds indicate?
a. Expected peristalsis
b. Femoral artery stenosis
c. Renal artery stenosis
d. Hyperactive bowel sounds
ANS: C

Feedback
A Expected peristalsis would be heard using the diaphragm of the stethoscope and would be a gurgling sound.
B Femoral artery stenosis is a vascular sound heard with the bell, but located in the lower abdomen.
C Renal artery stenosis is a vascular sound heard with the bell and located in the upper abdomen.
D Hyperactive bowel sounds would be heard using the diaphragm and would be present in all quadrants.
DIF: Cognitive Level: Understand REF: 274
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

16. What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient?
a. Bowel sounds
b. Venous hum
c. Soft, low-pitched murmur
d. No sounds
ANS: D

Feedback
A Bowel sounds are heard with the diaphragm of the stethoscope.
B Venous hum is not a normal finding.
C Soft, low-pitched murmur is not a normal finding.
D The bell is used to listen for vascular sounds and normally no vascular sounds are heard in the abdomen.
DIF: Cognitive Level: Understand REF: 274
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

17. What instructions does the nurse give a patient before palpating the abdomen?
a. Bend the knees.
b. Take a deep breath and hold it.
c. Take a deep breath and cough.
d. Place the hands over the head.
ANS: A

Feedback
A Bend the knees to relax the abdominal muscles.
B This action is not needed to assess the abdomen.
C This action is used to detect bulges in the abdomen, but not used before palpation.
D This action is not needed to assess the abdomen.
DIF: Cognitive Level: Remember REF: 275
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

18. A patient reports intermittent cramping abdominal pain that is relieved by having a bowel movement. The patient complains of having the pain at this time, which is why she is seeking care. Which abnormal finding does the nurse anticipate finding on examination of this patients abdomen?
a. Decreased bowel sounds
b. Bulge in the abdomen when coughing
c. Palpable mass in the left lower quadrant
d. Bruit around the umbilicus
ANS: C

Feedback
A Decreased bowel sounds are not expected if the patient is having bowel movements.
B Bulge in the abdomen when coughing is a finding associated with abdominal or incisional hernias.
C Palpable mass in the left lower quadrant is expected when interpreted with other dataage of the patient, intermittent cramping abdominal pain relieved by a bowel movementas consistent with diverticular disease.
D Bruit around the umbilicus is a finding associated with an abdominal aortic aneurysm.
DIF: Cognitive Level: Analyze REF: 269| 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

19. Using deep palpation of a patients epigastrium, a nurse feels a rhythmic pulsation of the aorta. Based on this finding, what is the nurses most appropriate response?
a. Auscultate this area using the bell of the stethoscope.
b. Percuss the area for tones.
c. Ask the patient if there is pain in this area.
d. Document this as a normal finding.
ANS: D

Feedback
A Auscultating this area using the bell of the stethoscope is not necessary because this is a normal finding. Vascular sounds are usually not heard.
B Percussing the area for tones is not necessary because this is a normal finding.
C Asking the patient if there is pain in this area is not necessary because this is a normal finding.
D Document this as a normal finding. The aorta is often palpable at the epigastrium.
DIF: Cognitive Level: Apply REF: 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

20. What technique does a nurse use when performing deep palpation of a patients abdomen?
a. Places the left hand under the ribs to lift them up
b. Asks the patient to breathe slowly through the mouth
c. Positions the patient on the right side with knees flexed
d. Uses the heel of the hand to depress the abdomen
ANS: B

Feedback
A Placing the left hand under the ribs to lift them up is the technique for palpating the liver.
B Asking the patient to breathe slowly through the mouth while the nurse uses the pads of the fingers to depress the abdomen is the correct procedure.
C Positioning the patient on the right side with knees flexed is an alternate strategy for palpating the spleen.
D Using the heel of the hand to depress the abdomen is not a correct technique; the pads of the fingers are used.
DIF: Cognitive Level: Understand REF: 275
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

21. To correctly percuss the abdomen, a nurse places the distal aspect of the middle finger of the nondominant hand against the skin of the abdomen, and the other fingers are spread apart and slightly lifted off the skin. How does the nurse use the fingers of the dominant hand?
a. The pad of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen.
b. The tip of the middle finger strikes the nail of the middle finger touching the skin of the abdomen.
c. The tip of the middle finger strikes the distal interphalangeal joint of the middle finger touching the skin of the abdomen.
d. The pads of the index and middle fingers strike the nail of the middle finger touching the skin of the abdomen.
ANS: C

Feedback
A This description is incorrect because the tip of the finger is used rather than the pad.
B This description is incorrect because the distal joint is struck rather than the nail.
C This is the correct technique.
D This description is incorrect because the tip of the middle finger strikes the distal joint.
DIF: Cognitive Level: Understand REF: 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

22. Which sound does a nurse expect to hear when percussing a patients abdomen?
a. Tympany over all quadrants
b. Resonance over the upper quadrants and tympany in the lower quadrants
c. Dull sounds over the upper quadrants and hollow sounds over the lower quadrants
d. Dull sounds over the stomach and resonant sounds over the bladder
ANS: A

Feedback
A Tympany over all quadrants is a normal finding, which represents the presence of gas.
B Resonance in the upper quadrants and tympany over the lower quadrants are not normal findings. There would be tympany in the lower quadrants, but also in the upper quadrants.
C Dull sounds over the lower quadrants and hollow sounds over the upper quadrants are not normal findings. There would be tympany over the lower quadrants, but also in the upper quadrants.
D Dull sounds over the stomach and resonant sounds over the bladder are not normal findings.
DIF: Cognitive Level: Understand REF: 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

23. A nurse expects which finding when assessing the abdomen of a patient who has been unable to void for 12 hours?
a. Absent bowel sounds
b. Hyperactive bowel sounds
c. Tympanic tones over the lower abdomen
d. Dull tones over the suprapubic area
ANS: D

Feedback
A Absent bowel sounds is incorrect because the bowel sounds would not be affected by a full bladder.
B Hyperactive bowel sounds is incorrect because the bowel sounds would not be affected by a full bladder.
C Tympanic tones over the lower abdomen is incorrect because tympany sound is created by gas in the abdomen.
D Dull tones over the suprapubic area would be found. The urine in the bladder would create a dull sound when the bladder is percussed similar to the sounds when an abdominal mass is present.
DIF: Cognitive Level: Apply REF: 276
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

24. When assessing an adults liver, the nurse percusses the lower border and finds it to be 5 cm below the costal margin. What is the nurses appropriate action at this time?
a. Document this as an expected finding for this adult.
b. Palpate the gallbladder for tenderness.
c. Palpate the upper liver border on deep inspiration.
d. Use the hooking technique to palpate the lower border of the liver.
ANS: C

Feedback
A Documenting this as a normal finding for an adult patient is incorrect because this finding indicates an enlarged liver.
B Palpating the gallbladder for tenderness is not indicated for an enlarged liver.
C Palpating the upper border of the liver on deep inspiration is the correct technique to use when an enlarged liver is found (as indicated by the liver being percussed 5 cm below the costal margin).
D Using the hooking technique to palpate the lower border of the liver is not needed because the liver is enlarged.
DIF: Cognitive Level: Apply REF: 277
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

25. Which location does a nurse select when palpating a patients liver?

a. A (right lower quadrant)
b. B (right upper quadrant)
c. C (left upper quadrant)
d. D (left lower quadrant)
ANS: B

Feedback
A The majority of the liver is located in the right upper quadrant of the abdomen.
B The majority of the liver is located in the right upper quadrant of the abdomen.
C C is the left upper quadrant.
D D is the left lower quadrant.
DIF: Cognitive Level: Understand REF: 273| 277
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

26. On palpation of the left upper quadrant of the abdomen of a female patient, the nurse notes tenderness. This finding may indicate a disorder in which organ?
a. Spleen
b. Gallbladder
c. Sigmoid colon
d. Left ovary
ANS: A

Feedback
A The spleen is located in the left upper quadrant of the abdomen.
B The gallbladder is located in the right upper quadrant of the abdomen.
C The sigmoid colon is located in the left lower quadrant of the abdomen.
D The left ovary is located in the left lower quadrant of the abdomen.
DIF: Cognitive Level: Apply REF: 265| 278
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

27. The nurse recognizes which clinical finding as expected on palpation of the abdomen?
a. Inability to palpate the spleen
b. Left kidney rounded at 2 cm below the costal margin
c. Slight tenderness of the gallbladder on light palpation
d. Bounding pulsation of the aorta over the umbilicus
ANS: A

Feedback
A Inability to palpate the spleen is the expected finding on palpating the abdomen.
B A rounded left kidney at 2 cm below the costal margin is not an expected finding. Kidneys are usually not palpated.
C Slight tenderness of the gallbladder on light palpation is not an expected finding; the gallbladder is usually not palpable.
D Bounding pulsation of the aorta over the umbilicus would be an abnormal finding, perhaps indicating an aneurysm.
DIF: Cognitive Level: Understand REF: 280
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

28. The nurse observes a patient rocking back and forth on the examination table in pain. Based on the patients history, the nurse suspects kidney stones. What additional examination technique does the nurse perform to confirm this suspicion?
a. Palpating the flank area for rebound tenderness
b. Percussing the bladder for fullness
c. Percussing the costal vertebral margins for tenderness
d. Palpating McBurney point for tenderness
ANS: C

Feedback
A Palpating the flank area for rebound tenderness is the correct location (flank area), but rebound tenderness is performed on the abdomen to detect peritoneal inflammation.
B Percussing the bladder for fullness would provide data about bladder distention, but is not a technique to detect for kidney stones.
C Percussing the costal vertebral margins for tenderness is the appropriate technique to detect kidney stones. The nurse recognizes the relationship between the history and the observation with further assessment techniques needed to confirm kidney stones.
D Palpating McBurney point for tenderness is a technique to detect appendicitis.
DIF: Cognitive Level: Analyze REF: 281-282
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

29. Which techniques does a nurse use to palpate a patients right kidney?
a. Asks the patient to take a deep breath, elevates the patients eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand
b. Asks the patient to exhale, elevates the patients eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand
c. Asks the patient to take a deep breath, elevates the patients right flank with the left hand, and deeply palpates for the right kidney with the right hand
d. Asks the patient to exhale, elevates the patients right flank with the left hand, and deeply palpates for the right kidney with the right hand
ANS: C

Feedback
A Asking the patient to take a deep breath, elevating the patients eleventh and twelfth ribs with the left hand, and deeply palpating for the right kidney with the right hand is incorrect because the flank is elevated rather than the ribs.
B Asking the patient to exhale, elevating the patients eleventh and twelfth ribs with the left hand, and deeply palpating for the right kidney with the right hand is incorrect because the flank is elevated rather than the ribs and the patient is asked to inhale rather than exhale.
C Asking the patient to take a deep breath, elevating the patients right flank with the left hand, and deeply palpating for the right kidney with the right hand is the correct technique.
D Asking the patient to exhale, elevating the patients right flank with the left hand, and deeply palpating for the right kidney with the right hand is incorrect because the patient is asked to inhale rather than exhale.
DIF: Cognitive Level: Apply REF: 280
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

30. When assessing the abdomen of a patient who has fluid in the peritoneal cavity, the nurse expects what change to occur when the patient turns from supine to the left side?
a. Movement of the tympanic tones from lateral in the supine position to closer to midline when lying on the left side
b. Movement of the dull tones from lateral in the supine position to closer to midline when lying on the left side
c. Change in bowel sounds from hypoactive in the supine position to hyperactive when lying on the left side
d. Change in bowel sounds from hyperactive in the supine position to hypoactive when lying on the left side
ANS: B

Feedback
A Movement of the tympanic tones from lateral in the supine position to closer to midline when lying on the left side is incorrect because the tone will be dull, rather than tympanic, due to the fluid.
B Movement of the dull tones from lateral in the supine position to closer to midline when lying on the left side is the expected change when assessing for shifting dullness.
C A change in bowel sounds from hypoactive in the supine position to hyperactive when lying on the left side is incorrect because bowel sounds would not be affected by the fluid.
D A change in bowel sounds from hyperactive in the supine position to hypoactive when lying on the left side is incorrect because bowel sounds would not be affected by the fluid.
DIF: Cognitive Level: Understand REF: 282-283
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

31. The patient reports right lower quadrant (RLQ) pain that is worse with coughing. Based on the patients history, the nurse suspects appendicitis. What additional examination technique does the nurse perform to confirm this suspicion?
a. Placing the hand over the lower right thigh and asking the patient to flex the knee while pushing down on the knee to resist it and noting if the patient complains of pain
b. Palpating deeply a point of the abdomen, located halfway between the umbilicus and the left anterior iliac crest
c. Asking the patient to flex the right hip and knee to 90 degrees, then abducting the leg and noting if the patient complains of pain
d. Pressing down in an area away from the RLQ at a 90-degree angle to the abdomen, then releasing the fingers quickly and noting any complaint of pain
ANS: D

Feedback
A This is an incorrect description of the iliopsoas muscle test.
B This is an incorrect description of the testing for McBurney point. McBurney point is located to the right of the umbilicus.
C This is an incorrect description of the obturator muscle test.
D This describes rebound tenderness, which is performed to detect peritoneal inflammation.
DIF: Cognitive Level: Analyze REF: 284-285
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

32. When palpating the abdomen to determine a floating mass, a nurse presses on the abdomen at a 90-degree angle with the fingertips. Which finding indicates a mass?
a. An increase in abdominal girth
b. A complaint from the patient of a dull pain in the flank area
c. A freely movable mass will float upward and touch the fingertips
d. Fluid in the abdomen will shift upward and touch the fingertips
ANS: C

Feedback
A An increase in abdominal girth does not occur as a result of ballottement.
B A complaint from the patient of a dull pain in the flank area is not an expected finding.
C A freely movable mass floating upward and touching the fingertips is the expected finding (ballottement).
D Fluid in the abdomen shifting upward and touching the fingertips does not occur; it is the mass on the abdomen that shifts upward.
DIF: Cognitive Level: Apply REF: 285
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

33. A 75-year-old male patient asks how to reduce his risk of esophageal cancer. What is the nurses most appropriate response?
a. Dont worry about it, esophageal cancers have a low incidence in men.
b. You should not be concerned about esophageal cancer at your age.
c. You should consider limiting your alcohol intake to two drinks per day.
d. Increasing the fiber and protein in your diet can help you lower your risk.
ANS: C

Feedback
A Men have a rate three times that of women.
B The risk increases with age, with the peak between 70 and 80 years.
C You should consider limiting your alcohol intake to two drinks per day. Long-term alcohol intake increases your risk for esophageal cancer.
D Although fiber and protein are important for the diet, their intake does not affect the risk of esophageal cancer.
DIF: Cognitive Level: Understand REF: 287
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Disease Prevention

34. Which patient has the lowest risk for colon cancer?
a. Patient A is 50 years old, is obese, and has type 2 diabetes mellitus.
b. Patient B is 60 years old, has alcoholism, and smokes a pack of cigarettes daily.
c. Patient C is 55 years old, has ulcerative colitis, and inflammatory bowel disease.
d. Patient D is 45 years old and has diverticulosis.
ANS: D

Feedback
A Patient A has three risk factors for colon cancer.
B Patient B has three risk factors for colon cancer.
C Patient C has two risk factors for colon cancer.
D Patient D has the lowest risk of colon cancer. Ninety percent of colon cancers occur in adults older than 50 years of age. Although this patient does have a disorder of the colon, it is not linked to an increased risk of colon cancer.
DIF: Cognitive Level: Analyze REF: 287
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Disease Prevention

35. Which assessment technique is the nurse performing in the figure below?

a. Direct percussion
b. Indirect percussion
c. Light palpation
d. Deep palpation
ANS: B

Feedback
A Direct percussion is performed with one hand.
B Indirect percussion is the technique shown.
C Light palpation is performed using the pads of the fingers depressing the tissue 1 to 2 cm, usually on the abdomen.
D Deep palpation is performed using the pads of the fingers depressing the tissue 4 to 6 cm, usually on the abdomen.
DIF: Cognitive Level: Apply REF: 282
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

MULTIPLE RESPONSE

1. A nurse suspects appendicitis in a patient with abdominal pain. Which findings are suggestive of appendicitis? Select all that apply.
a. Pain radiating to the right shoulder
b. Pain around the umbilicus
c. Pain relieved by lying still
d. Right lower quadrant pain
e. Increased peristalsis
ANS: B, C, D
Correct: These are all descriptions of pain related to appendicitis.
Incorrect: Pain radiating to the right shoulder is associated with gallbladder disease. Increased peristalsis can be associated with gastroenteritis or diarrhea.

DIF: Cognitive Level: Understand REF: 278-279
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

2. Alcoholism increases the risk of cancers of the gastrointestinal tract. Which cancer risk is increased in patients with alcoholism? Select all that apply.
a. Esophageal cancer
b. Stomach cancer
c. Pancreatic cancer
d. Liver cancer
e. Colon cancer
f. Bladder cancer
ANS: A, B, D, E
Correct: The risk of esophageal, stomach, liver, and colon cancers are increased by heavy intake of alcohol.
Incorrect: The risk of pancreatic and bladder cancers are increased with tobacco. However, the risk for esophageal, stomach, liver, and colon cancers are also increased with tobacco use.

DIF: Cognitive Level: Understand REF: 285-285
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Disease Prevention

OTHER

1. Put in correct order the steps used to palpate the liver.
A. Place your right hand parallel to the right costal margin.
B. Ask the patient to take a deep breath.
C. Place your right hand parallel to the right costal margin.
D. Lift up the eleventh and twelfth ribs with the left hand.
E. Press your right hand down and under the coastal margin.
F. Ask the patient to take some deep breaths

ANS:
D, C, A, E, B, F

DIF: Cognitive Level: Apply REF: 287
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

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