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Test Bank- Jarvis 3rd - Physical Examination & Health Assessment - Abdomen.(2023-2024), Exams of Nursing

City University of New York (CUNY) - City CollegeNursing
Prof. John Authur

Test Bank- Jarvis 3rd - Physical Examination & Health Assessment - Abdomen.(2023-2024)

Typology: Exams

2022/2023

Available from 07/10/2023

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NURSINGTB.COM
Chapter 22: Abdomen
Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition
MULTIPLE CHOICE
1. 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.
Hyper-resonance
ANS: A
The liver is located in the right upper quadrant (RUQ) and would elicit a dull percussion
note.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. When percussing the left lower quadrant of the abdomen, the nurse elicits a drumlike sound
normal for the:
a.
Liver
b.
Pancreas
c.
Left kidney
d.
Sigmoid colon
ANS: D
The sigmoid colon is a hollow organ located in the left lower quadrant of the abdomen.
Tympanic (drumlike) sounds are usually heard on percussion of hollow viscera.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
3. 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
ANS: 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 loss of
appetite.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
NURSINGTB.COM
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
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NURSINGTB.COM

Chapter 22: Abdomen

Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition

MULTIPLE CHOICE

  1. 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. Hyper-resonance ANS: A The liver is located in the right upper quadrant (RUQ) and would elicit a dull percussion note. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
  2. When percussing the left lower quadrant of the abdomen, the nurse elicits a drumlike sound normal for the: a. Liver b. Pancreas c. Left kidney d. Sigmoid colon ANS: D The sigmoid colon is a hollow organ located in the left lower quadrant of the abdomen. Tympanic (drumlike) sounds are usually heard on percussion of hollow viscera. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
  3. 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 ANS: 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 loss of appetite. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

NURSINGTB.COM

  1. 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 ANS: D Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
  2. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a. Increased salivation b. Increased liver size c. Increased esophageal emptying d. Decreased gastric acid secretion ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance
  3. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a. The spleen can be enlarged as a result of trauma. b. Normally, the spleen is felt on routine palpation. c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size. d. An enlarged spleen should not be palpated because it can easily rupture. ANS: D If an enlarged spleen is felt, then the nurse should refer the person and should not continue to palpate it. An enlarged spleen is friable and can easily rupture with over palpation. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
  4. During inspection of a 52-year-old patient, the nurse notes that the patient’s abdomen is bulging and stretched with dullness percussed to the left lower quadrant. The nurse will document that the patient: a. Is obese and on a weight loss program b. Has a hernia and awaiting surgery

NURSINGTB.COM

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

  1. The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows 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 prior prevents distortion of bowel sounds that might occur after percussion and palpation.” c. “Auscultation allows the patient more time to relax and thus be more comfortable with the physical examination.” d. “Auscultation prevents distortion of vascular sounds, such as bruits and hums, which might occur after percussion and palpation.” ANS: B Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would result in false interpretation of bowel sounds. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
  2. 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 ANS: B Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
  3. 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 ANS: D Borborygmi is the term used for hyperperistalsis when the person actually feels the stomach growling. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

NURSINGTB.COM

  1. During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area b. Tympanic percussion note in the umbilical region c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line d. Dull percussion note in the left upper quadrant at the midclavicular line ANS: B Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not 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). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
  2. 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 ANS: B Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
  3. 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, hyper-resonance, and dullness d. Resonance, hyper-resonance, and flatness ANS: 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; hyper-resonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, a mass, or solid organs, such as the liver. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
  4. An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:

NURSINGTB.COM

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

  1. The nurse notices that a patient has black, tarry stools and recognizes that they could indicate: a. Gallbladder disease b. Iron supplementation c. Gastrointestinal bleeding d. Localized bleeding around the anus ANS: C Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Red blood in stools occurs with localized bleeding around the anus. Stools may be black, but nontarry, with use of iron supplements. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
  2. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? a. Spleen b. Sigmoid c. Appendix d. Gallbladder ANS: C The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
  3. The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? a. Abdominal tone is increased. b. Abdominal musculature is thinner. c. Abdominal rigidity with an acute abdominal condition is more common. d. The older adult with an acute abdominal condition complains more about pain than the younger person. ANS: B In the older adult, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with an acute abdominal condition is less common in the aging person. The older adult with an acute abdominal condition often complains less about pain compared with a younger person. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

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  1. During an assessment of a newborn infant, the nurse recalls that pyloric 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 ANS: 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. An olive-sized mass can be palpated in the right upper quadrant (RUQ). DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance
  2. To detect diastasis recti, the nurse should ask the patient to perform which of these manoeuvres? a. Relaxing in the supine position b. Raising the arms in the left lateral position c. Raising the arms over the head while in a supine position d. Raising the head while in the supine position ANS: D Diastasis recti is a separation of the abdominal rectus muscles, which can occur congenitally, as a result of pregnancy or from significant obesity. Diastasis recti is assessed by having the patient raise the head while remaining in the supine position. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
  3. During abdominal assessment of an adult patient, the nurse auscultates a bruit in the upper abdomen area just left of the midline. The nurse will: a. Palpate the area b. Document the findings as normal c. Report the findings immediately d. Assess for rebound tenderness ANS: C If a bruit is heard on auscultation, the area should not be palpated, to avoid rupturing an abdominal aortic aneurysm. The findings should be reported immediately. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
  4. 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

NURSINGTB.COM

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

  1. A 40-year-old man states that his physician diagnosed him with 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 that has pushed 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.” ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
  2. 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 ANS: 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. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
  3. When palpating the abdomen of a 20-year-old patient who was injured in a motor vehicle accident, 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 ANS: A The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the RUQ, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

NURSINGTB.COM

  1. The 22-year-old patient informs the nurse she feels bloated and has diarrhea when she drinks milkshakes and eats ice cream. The nurse recognizes this as possible: a. Celiac disease b. Lactose intolerance c. Cholecystitis d. Wheat allergy ANS: B Lactose intolerance results from lactase deficiency and can cause bloating, excessive gas or diarrhea after ingesting dairy products, such as milkshakes and ice cream. Wheat allergy or gluten intolerance (e.g., Celiac disease) can result in abdominal pain, distension, or diarrhea. Cholecystitis is biliary colic, which causes sudden pain in the RUQ that may radiate to the right or left scapula and builds over time, lasting 2 to 4 hours, after ingestion of fatty foods, alcohol, or caffeine. It is associated with nausea and vomiting and a positive Murphy’s sign (sudden stop in inspiration with RUQ palpation). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance
  2. The nurse is assessing a 60-year-old male patient with sharp upper abdominal pain. What additional finding during history taking indicates possible peptic ulcer disease? a. Lactose intolerance b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs) ANS: D Peptic ulcer disease increases with age and occurs with frequent use of NSAIDs, excessive alcohol consumption, smoking, and infection by Helicobacter pylori. Eight to 10 million Canadians have H. pylori infection, which is also associated with development of stomach cancer; approximately 75% of Indigenous peoples are infected by H. pylori. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
  3. During assessment of a patient with chronic emphysema, the nurse recognizes that percussing the liver border below the right costal margin: a. Can indicate liver cirrhosis b. Indicates hepatomegaly c. Requires immediate reporting of findings d. Is an expected finding in this patient ANS: D For people with chronic emphysema, the liver is displaced downward by the hyperinflated lungs. Although a dull percussion note can be heard well below the right costal margin, the overall span is still within normal limits. Hepatomegaly refers to an enlarged liver. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

NURSINGTB.COM

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 result in false interpretation of bowel sounds. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

  1. During the 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!” On the basis of these symptoms, the nurse suspects that the patient has which condition? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may be 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. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE
  2. 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 Murphy’s sign b. Test for Blumberg’s sign c. Test for shifting dullness d. Perform the iliopsoas muscle test e. Test for fluid wave ANS: B, D Testing for Blumberg’s sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. Murphy’s 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. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
  3. When inspecting a patient’s abdomen, the nurse notes an old surgical scar at midline extending vertically below the umbilicus. The nurse will: ( Select all that apply. ) a. Not be concerned with it because it is an old scar. b. Ask the patient about the scar. c. Not consider it relevant because the patient did not identify it.

NURSINGTB.COM

d. Include a drawing of the scar’s location on the abdomen in the documentation. e. Measure and record the length of the scar in the documentation. ANS: B, D, E If a scar is present, the patient should be asked about it, and a drawing of its location and length in centimetres should be included in the patient’s record (Figure 22-10). A surgical scar is an indication of the possible presence of underlying adhesions and excess fibrous tissue. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation