Jarvis Chapter 21
29. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympany in the right and left lower quadrants
A A large amount of ascitic fluid produces a dull sound to percussion. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 553 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
33. 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
A A recent study found estimates of lactose-intolerance prevalence as follows: 19.5% for Blacks, 10% for Hispanics, and 7.72% for Whites. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 541 MSC: Client Needs: Health Promotion and Maintenance
19. A nurse notices that a patient has ascites, which indicates the presence of: a. Fluid. b. Feces. c. Flatus. d. Fibroid tumors.
A Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 553 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
28. 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."
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, hardens, and falls off in 10 to 14 days. Skin will cover the area in 3 to 4 weeks. DIF: Cognitive Level: Applying (Application) REF: p. 561 MSC: Client Needs: Health Promotion and Maintenance
24. 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.
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. DIF: Cognitive Level: Applying (Application) REF: p. 572 MSC: Client Needs: Health Promotion and Maintenance
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
A The liver is located in the right upper quadrant and would elicit a dull percussion note. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 550 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
32. 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
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. DIF: Cognitive Level: Applying (Application) REF: p. 540 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
35. During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to: a. Enlarged liver. b. Enlarged spleen. c. Distended bowel. d. Excessive diarrhea.
A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 551 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
26. 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.
B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent. DIF: Cognitive Level: Applying (Application) REF: p. 549 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
11. 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."
B Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. DIF: Cognitive Level: Applying (Application) REF: p. 548 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. 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.
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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 549 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. 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.
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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 549 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
17. 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.
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. DIF: Cognitive Level: Applying (Application) REF: p. 541 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
23. 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.
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 than the younger person. DIF: Cognitive Level: Applying (Application) REF: p. 563 MSC: Client Needs: Health Promotion and Maintenance
27. 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
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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 560 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
15. 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.
B Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct. DIF: Cognitive Level: Applying (Application) REF: p. 540 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
30. 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."
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) REF: p. 546 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
38. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds.
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. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 555 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
14. 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
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) REF: p. 550 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
20. The nurse knows that during an abdominal assessment, deep palpation is used to determine: a. Bowel motility. b. Enlarged organs. c. Superficial tenderness. d. Overall impression of skin surface and superficial musculature.
B With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 554 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
1. 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
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. DIF: Cognitive Level: Applying (Application) REF: p. 560 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
21. The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a. Gallbladder disease. b. Overuse of laxatives. c. Gastrointestinal bleeding. d. Localized bleeding around the anus.
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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 543 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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.
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. DIF: Cognitive Level: Applying (Application) REF: p. 542 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
25. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true 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.
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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 574 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are: a. Pulsations of the renal arteries. b. Pulsations of the inferior vena cava. c. Normal abdominal aortic pulsations. d. Increased peristalsis from a bowel obstruction.
C Normally, the pulsations from the aorta are observed beneath the skin in the epigastric area, particularly in thin persons who have good muscle wall relaxation. DIF: Cognitive Level: Applying (Application) REF: p. 549 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
39. 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
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. DIF: Cognitive Level: Applying (Application) REF: p. 570 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
16. 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.
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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 550 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. 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.
C Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct. DIF: Cognitive Level: Applying (Application) REF: p. 552 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
22. 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
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) REF: p. 560 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
36. During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? a. Intra-abdominal bleeding b. Constipation c. Umbilical hernia d. Abdominal tumor
C The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect. DIF: Cognitive Level: Applying (Application) REF: p. 546 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
31. 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.
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) REF: p. 550 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
7. A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: a. Obese. b. Herniated. c. Scaphoid. d. Protuberant.
D A protuberant abdomen is rounded, bulging, and stretched (see Figure 21-7). A scaphoid abdomen caves inward. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 546 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
13. 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.
D Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 549 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ______ profile. a. Flat b. Convex c. Bulging d. Concave
D Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane (see Figure 21-7). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 546 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
4. 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.
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) REF: p. 540 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. 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.
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) REF: p. 541 MSC: Client Needs: Health Promotion and Maintenance
6. 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. The spleen is normally 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.
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 overpalpation. DIF: Cognitive Level: Applying (Application) REF: p. 558 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
37. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a. Splenomegaly. b. Distended bladder. c. Constipation. d. Ascites.
D If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation. DIF: Cognitive Level: Applying (Application) REF: p. 553 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
34. The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem? a. Hypertension b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal antiinflammatory drugs
D Peptic ulcer disease occurs with the frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infection. DIF: Cognitive Level: Applying (Application) REF: p. 543 MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum c. Gallbladder d. Sigmoid colon
D The sigmoid colon is located in the left lower quadrant of the abdomen. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 540 MSC: Client Needs: General