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The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b. Tympany c. Resonance d. Hyperresonance Answer- a (The liver is located in the right upper quadrant and would elicit a dull percussion note.) Which structure is located in the left lower quadrant of the abdomen? a.Liver b.Duodenum c.Gallbladder d.Sigmoid colon Answer- d (The sigmoid colon is located in the left lower quadrant of the abdomen.) A patient is having difficulty swallowing medications and food. The nurse would document that this patient has: a. Aphasia. b. Dysphasia. c. Dysphagia. d. Anorexia. Answer- c (Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite.) The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region. b. Inspect and palpate in the epigastric region. c. Auscultate and percuss in the inguinal region. d. Percuss and palpate the midline area above the suprapubic bone. Answer- d (Dull percussion sounds would be elicited over a distended bladder, and the
HAP FINAL EXAM STUDY QUESTIONS
WITH CORRECT ANSWERS.
hypogastric area would seem firm to palpation.)
epigastric area, particularly in thin persons who have good muscle wall relaxation.) A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
a. Diarrhea. b. Peritonitis. c. Laxative use. d. Gastroenteritis. Answer- B (Diminished or absent bowel sounds signal decreased motility from inflammation as exhibited with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.) The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a. "We need to determine the areas of tenderness before using percussion and palpation." b. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." c. "Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." d. "Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation." Answer- B (Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.) The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds: a. Are usually loud, high-pitched, rushing, and tinkling sounds. b. Are usually high-pitched, gurgling, and irregular sounds. c. Sound like two pieces of leather being rubbed together. d. Originate from the movement of air and fluid through the large intestine. Answer- B (Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.) The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a. Loud continual hum. b. Peritoneal friction rub. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds. Answer- D (Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.) During an abdominal assessment, the nurse would consider which of these findings as normal?
usually present. Normally, the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).) The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. Diarrhea. b. Pyrosis. c. Dysphagia. d. Constipation. Answer- b (Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct.) The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. Flatness, resonance, and dullness. b. Resonance, dullness, and tympany. c. Tympany, hyperresonance, and dullness. d. Resonance, hyperresonance, and flatness. Answer- C (Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.) An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. Increased gastric acid secretion. b. Decreased gastric acid secretion. c. Delayed gastrointestinal emptying time. d. Increased gastrointestinal emptying time. Answer- B (Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium.) A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of: a. Ovary infection. b. Liver enlargement. c. Kidney inflammation. d. Spleen enlargement. Answer- C (Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct.) A nurse notices that a patient has ascites, which indicates the presence of: a. Fluid.
b. Feces. c. Flatus. d. Fibroid tumors. Answer- A (Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.)
stenosis would be exhibited by: a. Projectile vomiting. b. Hypoactive bowel activity. c. Palpable olive-sized mass in the right lower quadrant. d. Pronounced peristaltic waves crossing from right to left. Answer- A
(Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive- sized mass in the right upper quadrant.) The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements istrue regarding an aortic aneurysm? a. A bruit is absent. b. Femoral pulses are increased. c. A pulsating mass is usually present. d. Most are located below the umbilicus. Answer- C (Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.) During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least: a. 1 minute. b. 5 minutes. c. 10 minutes. d. 2 minutes in each quadrant. Answer- B (Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent.) A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b. Test for Murphy sign c. Assess for rebound tenderness d. Iliopsoas muscle test Answer- B (Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy test). The person feels sharp pain and abruptly stops midway during inspiration.) Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a. "It should fall off in 10 to 14 days." b. "It will soften before it falls off." c. "It contains two veins and one artery." d. "Skin will cover the area within 1 week." Answer- A (At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton jelly. The umbilical stump dries within a week,
b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympany in the right and left lower quadrants Answer- A (A large amount of ascitic fluid produces a dull sound to percussion.) A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. "No need to worry. Most men your age develop hernias." b. "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." c. "A hernia is the result of prenatal growth abnormalities that are just now causing problems." d. "I'll have to have your physician explain this to you." Answer- B (The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall.) A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d. Consider this finding as normal, and proceed with the examination. Answer- D (A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.) When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Sigmoid colon c. Appendix d. Gallbladder Answer- A (The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.) The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? a. Blacks b. Hispanics
c. Whites d. Asians Answer- A (A recent study found estimates of lactose-intolerance prevalence as follows: 19.5% for Blacks, 10% for Hispanics, and 7.72% for Whites.)
d. Palpate the tender area first, and then auscultate for bowel sounds. Answer- B (The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and
palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.) During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!" Based on these symptoms, the nurse suspects that the patient has which condition? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis Answer- C (Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may relieved by more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.) The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. a. Test for the Murphy sign b. Test for the Blumberg sign c. Test for shifting dullness d. Perform the iliopsoas muscle test e. Test for fluid wave Answer- B, D (Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites.) A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman? a. Dilated pupils, pacing, and psychomotor agitation b. Dilated pupils, unsteady gait, and aggressiveness c. Pupil constriction, lethargy, apathy, and dysphoria d. Constricted pupils, euphoria, and decreased temperature Answer- A (A cocaine user's appearance includes pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The person's behavior includes euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, and visual or tactile hallucinations.) The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. During the physical assessment, the
fibrillation, bradycardia, and mitral valve prolapse are not associated with chronic heavy use of alcohol.) The nurse is conducting a class on alcohol and the effects of alcohol on the body. How many standard drinks (each containing 14 grams of alcohol) per day in men are associated with increased deaths from cirrhosis, cancers of the mouth, esophagus, and injuries? a. 2 b. 4 c. 6 d. 8 Answer- B (In men, alcohol consumption of at least four standard drinks per day is associated with increased deaths from liver cirrhosis, cancers of the mouth, esophagus and other areas, and deaths from injuries and other external causes.) During a session on substance abuse, the nurse is reviewing statistics with the class. For persons aged 12 years and older, which illicit substance was most commonly used? a. Crack cocaine b. Heroin c. Marijuana d. Hallucinogens Answer- C (In persons age 12 years and older who reported using during the past month, marijuana (hashish) was the most commonly used illicit drug reported.) A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse, "How many drinks a day is safe for my baby?" The nurse's best response is: a. "You should limit your drinking to once or twice a week." b. "It's okay to have up to two glasses of wine a day." c. "As long as you avoid getting drunk, you should be safe." d. "No amount of alcohol has been determined to be safe during pregnancy." Answer- D (No amount of alcohol has been determined to be safe for pregnant women. The potential adverse effects of alcohol use on the fetus are well known; women who are pregnant should be screened for alcohol use, and abstinence should be recommended.) When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? a. Increased muscle mass b. Decreased liver and kidney functioning c. Decreased blood pressure
d. Increased cardiac output Answer- B (Decreased liver and kidney functioning increases the bioavailability of alcohol in the blood for longer periods. Aging people experience decreased muscle mass (not increased), which also increases the alcohol concentration in the blood because the
