Ch. 18: Abdomen

7. Mr. Robins is a 45-year-old man who presents to the emergency department with a complaint of constipation. During auscultation, you note borborygmi sounds. This is associated with: a. gastroenteritis. b. peritonitis. c. satiety. d. paralytic ileus.

A Borborygmi are prolonged loud gurgles that occur with gastroenteritis, early intestinal obstruction, or hunger. Peritonitis and paralytic ileus result in hypoactive bowel sounds. Food satiety does not stimulate growling sounds as does hunger.

1. Mrs. James is 7 months' pregnant and states that she has developed a problem with constipation. She eats a well-balanced diet and is usually regular. You should explain that constipation is common during pregnancy because of changes in the colorectal areas, such as: a. decreased movement through the colon and increased water absorption from the stool. b. increased movement through the colon and increased salt taken from foods. c. looser anal sphincter and fewer nutrients taken from foods. d. tighter anal sphincter and less iron eliminated in the stool.

A Constipation and flatus are more common during pregnancy because the colon is displaced, peristalsis is decreased, and water absorption is increased. Movement through the colon is decreased during pregnancy. The colon does not absorb nutrients. A tighter sphincter tone is not related to pregnancy.

9. Mrs. G is 7 months' pregnant and states that she has developed a problem with constipation. She eats a well-balanced diet and is usually regular. You should explain that constipation is common during pregnancy because of changes in the colorectal areas, such as: a. decreased movement through the colon and increased water absorption from stool. b. increased movement through the colon and increased salt taken from foods. c. looser anal sphincter and less nutrients taken from foods. d. tighter anal sphincter and less iron eliminated in the stool. e. increased absorption of nutrients and water in the colon.

A Constipation and flatus are more common during pregnancy because the colon is displaced, peristalsis is decreased, and water absorption is increased. The colon does not absorb nutrients, and a tighter sphincter tone is not related to pregnancy.

19. Peritonitis often produces bowel sounds that are: a. decreased. b. increased. c. high pitched. d. absent. e. accentuated.

A Decreased bowel sounds occur with peritonitis and paralytic ileus.

31. Baby Joe is 6 months old. He has abdominal distention and vomiting and is inconsolable. A sausage-shaped mass is palpable in his right upper quadrant. Joe's lower quadrant feels empty, and a positive Dance sign is noted in his record. Which one of the following conditions is consistent with Baby Joe's symptoms? a. Intussusception b. Kidney stones c. Meconium ileus d. Pyloric stenosis e. Necrotizing enterocolitis

A Intussusception refers to the prolapse of one segment of the intestine into another causing intestinal obstruction. Whereas a sausage-shaped mass may be palpated in the right or left upper quadrant, the lower quadrant feels empty (positive Dance sign); it commonly occurs between 3 and 12 months of age.

16. Flatulence, diarrhea, dysuria, and tenderness with abdominal palpation are findings usually associated with: a. diverticulitis. b. pancreatitis. c. ruptured ovarian cyst. d. splenic rupture.

A Only diverticulitis has all these presenting symptoms.

10. When percussing a spleen, Traube's space is a: a. semilunar region. b. splenic percussion sign. c. left-sided pleural effusion. d. solid mass.

A Percussion of the spleen is more difficult because percussion tones elicited may be caused by other conditions. Traube's space is a semilunar region defined by the sixth ribs superiorly, the midaxillary line laterally, and the left costal margin inferiorly.

16. What condition is associated with striae that remain purplish? a. Cushing disease b. Diastasis recti c. Liver cirrhosis d. Recent pregnancy e. Intraabdominal bleeding

A Striae from pregnancy or obesity begin as a pink or purple color then turn silvery white; striae associated with Cushing disease stay purplish.

13. Which structure is located in the hypogastric region of the abdomen? a. Bladder b. Cecum c. Gallbladder d. Stomach e. Liver

A The hypogastric (pubic) area contains the ileum, the bladder, and the pregnant uterus.

6. The major function of the large intestine is: a. water absorption. b. food digestion. c. carbohydrate absorption. d. mucous absorption. e. glycogen breakdown.

A The major function of the large intestine is the absorption of water and excretion of solid waste material in the form of stool. Mucous glands secrete large quantities of alkaline mucus.

1. Your patient is a 48-year-old woman with complaints of severe cramping pain in the abdomen and right flank. Her past medical history includes a history of bladder calculi. You diagnose her with renal calculi at this time. Which of the following symptoms would you expect with her diagnosis? (Select all that apply.) a. Abdominal pain on palpation b. Blumberg sign c. Cullen sign d. CVA tenderness e. Fever f. Grey Turner sign g. Hematuria h. Nausea

A, D, E, G Abdominal pain on palpation, CVA tenderness, fever, hematuria, and nausea are all signs and symptoms of renal calculi. The Cullen sign is ecchymosis around the umbilicus, the Blumberg sign is rebound tenderness for appendicitis, the Grey Turner sign is ecchymosis in the flanks, and the McBurney sign is rebound tenderness at McBurney's point.

20. An examiner can recognize a friction rub in the liver by a sound that is: a. clicking, gurgling, and irregular. b. high pitched and associated with respirations. c. loud, prolonged, and gurgling. d. soft, low-pitched, and continuous. e. low pitched, tinkling, and unrelated to respirations.

B An abdominal friction rub is rare and can be identified when high-pitched sounds are auscultated in association with respirations.

11. The family history of a patient with diarrhea and abdominal pain should include inquiry about cystic fibrosis because it: a. only affects the GI tract. b. is one cause of malabsorption syndrome. c. is a curable condition with medical intervention. d. is the most frequent cause of diarrhea in general practice. e. is a common genetic disorder.

B Cystic fibrosis is an uncommon, chronic genetic disorder affecting multiple systems. In the gastrointestinal tract, it causes malabsorption syndrome because of pancreatic lipase deficiency. Steatorrhea and abdominal pain from increased gas production are frequent concerns.

25. Failure to pass a meconium stool in the first 24 hours after birth along with abdominal distention is often the first sign of: a. Meckel diverticulum. b. cystic fibrosis. c. biliary atresia. d. hydramnios. e. Wilms tumor.

B Meconium ileus is often the first manifestation of cystic fibrosis or Hirschsprung disease.

4. Infants born weighing less than 1500 g are at higher risk for: a. hepatitis A. b. necrotizing enterocolitis. c. urinary urgency. d. pancreatitis.

B Necrotizing enterocolitis is a gastrointestinal disease that mostly affects premature infants. It involves infection and inflammation that cause destruction of the bowel, and it becomes more apparent after feedings.

12. Infants born weighing less than 1500 g are at higher risk for: a. hepatitis A. b. necrotizing enterocolitis. c. urinary urgency. d. cystic fibrosis. e. pancreatitis.

B Necrotizing enterocolitis is a gastrointestinal disease that mostly affects premature infants; it involves infection and inflammation that causes destruction of the bowel, and it becomes more apparent after feedings. Low birth weight does not relate to the development of hepatitis A, urinary urgency, cystic fibrosis, or pancreatitis.

17. Visible intestinal peristalsis may indicate: a. normal digestion. b. intestinal obstruction. c. increased pulse pressure of aorta. d. aortic aneurysm. e. paralytic ileus.

B Peristalsis is not usually visible and when detected may indicate an intestinal obstruction.

3. The appendix is an extension of the: a. ileum. b. cecum. c. ascending colon. d. transverse colon. e. descending colon.

B The appendix is a blind-ended tube connected to the cecum, the site of the beginning of the large intestine, located in the right lower quadrant of the abdomen. It develops embryologically from the cecum.

15. When using the bimanual technique for palpating the abdomen, you should: a. push down with the bottom hand and the other hand on top. b. push down with the top hand and concentrate on sensation with the bottom hand. c. place the hands side by side and push equally. d. place one hand anteriorly and the other hand posteriorly, squeezing the hands together.

B The bimanual technique uses one hand on top of the other. Exert pressure with the top hand while concentrating on sensation with the other hand.

2. The superior most part of the stomach is the: a. body. b. fundus. c. pylorus. d. cardiac orifice. e. pyloric orifice.

B The most superior aspect of the stomach is the fundus, followed by the body, and then the most distal part, the pylorus.

5. The majority of nutrient absorption takes place in the: a. stomach. b. small intestine. c. cecum. d. transverse colon. e. descending colon.

B Very little absorption takes place in the stomach; most absorption takes place in the small intestine. The cecum and transverse colon are part of the large intestine, and its major function is water reabsorption.

2. Your patient returns to the office with multiple complaints regarding her abdomen. Which of the following are objective findings? (Select all that apply.) a. Nausea b. Dullness on percussion c. Rebound tenderness d. Vomiting e. Diarrhea f. Burning pain in epigastrium

B, C, E, F Nausea, vomiting and diarrhea, and burning pain in epigastrium are subjective signs. Dullness on percussion and rebound tenderness are objective findings.

14. Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition? a. Positive psoas sign b. Positive McBurney sign c. Consistent right lower quadrant (RLQ) pain d. Rebound tenderness

C A positive psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the RLQ are signs of appendicitis. The absence of pain migration makes appendicitis less likely.

11. Your patient is complaining of acute, intense, sharp epigastric pain that radiates to the back and left scapula, with nausea and vomiting. Based on this history, your prioritized physical examination should be to: a. percuss for ascites. b. assess for rebound tenderness. c. inspect for ecchymosis of the flank. d. auscultate for abdominal bruits.

C Abdominal pain that radiates to the back could be caused by pancreatitis or a gastric ulcer, gallbladder pain usually radiates to the right or left scapula but not to the back, pancreatitis pain can radiate to the left shoulder or scapula, and nausea and vomiting usually occur with gallbladder, pancreas, or appendix conditions. Pancreatitis is a differential diagnosis for all these symptoms, so begin the examination by inspecting the flanks for the Grey Turner sign, an indication of pancreatitis.

18. After thorough inspection of the abdomen, the next assessment step is to: a. percuss. b. palpate nonpainful areas. c. auscultate. d. perform a rectal examination. e. palpate painful areas.

C Assessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence is because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.

17. A 51-year-old woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to: a. use a topical, over-the-counter hemorrhoid treatment for 1 week. b. exercise and eat more fiber. c. come to the laboratory for a stool guaiac test. d. eat six small meals a day.

C Blood in the stool is an abnormal finding that should never be ignored, even if it can be explained by conditions other than colon cancer. She should have her stool checked for blood now as well as annually because she is older than 50 years.

20. In older adults, overflow fecal incontinence is commonly caused by: a. malabsorption. b. parasitic diarrhea. c. fecal impaction. d. fistula formation.

C Constipation with overflow occurs when the rectum contains hard stool and soft feces above a leak around the mass of stool.

12. To assess for liver enlargement in the obese person, you should: a. use the hook method. b. have the patient lean over at the waist. c. auscultate using the scratch technique. d. attempt palpation during deep exhalation.

C If the abdomen is obese or distended, or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver.

33. Given the high certainty that screening results in reduced mortality, current recommendations include screening for colorectal cancer beginning at age 50 and continuing until age: a. 65. b. 70. c. 75. d. 80. e. 85.

C In 2016 the U.S. Preventive Services Task Force (USPSTF) updated its previous recommendations based on a review of the evidence assessing both benefits and harms of screening. Given the high certainty that screening results in reduced mortality, the USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. Screening for colorectal cancer in adults ages 76 to 85 years should be an individual one, taking into account the patient's overall health and prior screening history.

18. Costovertebral angle tenderness should be assessed whenever you suspect that the patient may have: a. cholecystitis. b. pancreatitis. c. pyelonephritis. d. ulcerative colitis.

C Pyelonephritis is characterized by flank pain and costovertebral angle tenderness.

7. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: a. spleen. b. kidney. c. liver. d. pancreas. e. gallbladder.

C The liver is responsible for converting fat-soluble waste to water-soluble materials so the kidneys can excrete them as well as convert ammonia to urea.

4. One major function of the liver is to: a. secrete pepsin. b. emulsify fats. c. store glycogen. d. absorb bile. e. produce insulin.

C The liver plays a metabolic role; it converts glucose to glycogen, stores it, and then converts glycogen back to glucose as needed by the body.

1. Peristalsis of intestinal contents is under the control of: a. cognitive processes. b. gravity. c. the autonomic nervous system. d. the fluid content of the stomach. e. cerebellum.

C The movement of food and digestive products is regulated by the autonomic nervous system.

28. A 45-year-old man relates a several-week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a(n): a. elevated white blood cell count. b. decreased potassium level. c. positive Helicobacter pylori result. d. increased urine specific gravity. e. folate deficiency.

C The patient's presenting symptoms suggest peptic ulcer disease. The supporting laboratory finding is the presence of H. pylori.

5. You are completing a general physical examination on Mr. Rock, a 39-year-old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient: a. hold his or her breath. b. sit upright. c. flex his or her knees. d. raise his or her head off the pillow.

C To help relax the abdominal musculature, it is helpful to place a small pillow under the patient's head and under slightly flexed knees. The other techniques are not helpful because they increase muscle flexion.

24. An umbilical assessment in the newborn that is of concern is: a. a thick cord. b. an umbilical hernia. c. one umbilical artery and two veins. d. pulsations superior to the umbilicus. e. visible nondistended superficial veins.

C What is expected is two arteries and one vein. A single umbilical artery indicates the possibility of congenital anomalies. A thick cord suggests a well-nourished fetus, an umbilical hernia will generally spontaneously close by 2 years, and pulsations to the abdomen in the epigastric area are common. Nondistended superficial veins are usually visible in thin infants.

19. A mother brings her 2-year-old child for you to assess. The mother feels a lump whenever she fastens the child's diaper. Nephroblastoma is a likely diagnosis for this child when your physical examination of the abdomen reveals a(n): a. fixed mass palpated in the hypogastric area. b. tender, midline abdominal mass. c. olive-sized mass of the right upper quadrant. d. nontender, slightly movable, flank mass.

D A Wilms tumor (nephroblastoma) is the most common intraabdominal tumor of childhood. It presents with hypertension, fever, malaise, and a firm nontender mass deep within the flank that is only slightly movable and is usually unilateral.

10. The most pronounced functional change of the gastrointestinal (GI) tract in older adults is: a. decreased hydrochloric acid production. b. increased motility. c. decreased bile absorption. d. decreased motility. e. increased saliva secretion.

D A decrease in motility of the gastrointestinal (GI) tract is the most pronounced GI change in older adults.

6. Mrs. Little is a 44-year-old patient who presents to the office with abdominal pain and fever. During your examination, you ask the patient to raise her head and shoulders while she lies in a supine position. A midline abdominal ridge rises. You document this observation as a(n): a. small inguinal hernia. b. large epigastric hernia. c. abdominal lipoma. d. diastasis recti.

D A diastasis recti occurs when the abdominal contents bulge between two abdominal muscles to form a midline ridge as the head is lifted. It has little clinical significance and usually occurs in women who have had repeated pregnancies and in obese patients.

21. To correctly document absent bowel sounds, one must listen continuously for: a. 30 seconds. b. 1 minute. c. 3 minutes. d. 5 minutes. e. 10 minutes.

D Absent bowel sounds are confirmed after listening to each quadrant for 5 minutes.

3. When assessing abdominal pain in a college-age woman, one must include: a. history of interstate travel. b. food likes and dislikes. c. age at completion of toilet training. d. the first day of the last menstrual period.

D Exploring abdominal pain complaints in a young woman can reveal multiple causes related to the menstrual cycle, including menstrual pain, ovulation discomfort, and abnormal menses. Asking the patient to tell you the first day of her last menstrual period can help discriminate among these factors. History of international travel and traveler's diarrhea can be related to abdominal pain, but interstate travel usually does not. Food preferences and age at completion of toilet training are not relevant.

30. The most common congenital anomaly of the gastrointestinal tract is: a. biliary atresia. b. meconium ileus. c. intussusception. d. Meckel diverticulum. e. pyloric stenosis.

D Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract.

23. Percussion of the abdomen begins with establishing: a. liver dullness. b. spleen dullness. c. gastric bubble tympany. d. overall dullness and tympany in all quadrants. e. bladder fullness.

D Percussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs.

9. Percussion of the abdomen begins with establishing: a. liver dullness. b. spleen dullness. c. gastric bubble tympany. d. overall dullness and tympany in all quadrants.

D Percussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs.

27. Flatulence, diarrhea, dysuria, and tenderness with abdominal palpation are findings most associated with: a. peptic ulcer disease. b. pancreatitis. c. ruptured ovarian cyst. d. splenic rupture. e. diverticulitis.

E No choice other than diverticulitis has all of these presenting symptoms.

26. A patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition early in its course? a. Positive psoas sign b. Positive McBurney sign c. History of periumbilical pain d. Rebound tenderness e. Obturator muscle test

E Psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the right lower quadrant are signs of appendicitis. Conditions that cause irritation of the obturator muscle are late findings usually associated with a ruptured appendix or pelvic abscess.

8. Which abdominal organs also produce hormones and function as endocrine glands? a. Kidney and liver b. Liver and gallbladder c. Stomach and spleen d. Gallbladder and pancreas e. Pancreas and kidney

E The pancreas produces pancreatic juices as well as insulin and glucagon; the kidneys produce urine as well as the hormones rennin and erythropoietin.

22. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? a. Arterial bruit b. Gastric rumbling c. Renal hyperresonance d. Borborygmi e. Venous hum

E Venous hum is associated with blood flow in venous collaterals found in portal hypertension. Aortic bruit occurs during systole, and a venous hum is a continuous sound and softer than a bruit. The other choices are not vascular sounds.