Chapter 21 JARVIS

19. A nurse notices that a patient has *ascites*, which indicates the presence of:

A) fluid.

3. A patient is having *difficulty in swallowing* medications and food. The nurse would document that this patient has:

C) dysphagia.

21. The nurse notices that a patient has had a *black, tarry stool* and recalls that a possible cause would be:

C) gastrointestinal bleeding.

18. A patient is complaining of a *sharp pain along the costovertebral angles*. The nurse knows that this symptom is most often indicative of:

C) kidney inflammation.

9. While examining a patient, the nurse observes *abdominal pulsations between the xiphoid and umbilicus*. The nurse would suspect that these are:

C) normal abdominal aortic pulsations.

13. The physician comments that a patient has *abdominal borborygmi*. The nurse knows that this term refers to:

D) hyperactive bowel sounds.

7. A patient's abdomen is *bulging and stretched in appearance*. The nurse should describe this finding as:

D) protuberant.

29. 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 by 10 to 14 days."

34. 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) African-Americans

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

30. 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

33. 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

36. During report, the student nurse hears that a patient has "*hepatomegaly*" and recognizes that this term refers to:

A) an enlarged liver.

24. During an assessment of a newborn infant, the nurse recalls that *pyloric stenosis* would be manifested by:

A) projectile vomiting.

37. During an assessment the nurse notices that a patient's *umbilicus is enlarged and everted. It is midline, and there is no change in skin color*. The nurse recognizes that the patient may have which condition?

C) Umbilical hernia

31. 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?

B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."

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*?

B) "It prevents distortion of bowel sounds that might occur after percussion and palpation."

27. 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:

B) 5 minutes.

14. During an abdominal assessment, the nurse would consider which of these findings as *normal*?

B) A tympanic percussion note in the umbilical region

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*.

B) Test for Blumberg's sign. D) Perform iliopsoas muscle test.

28. 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?

B) Test for Murphy's sign

23. The nurse is assessing the *abdomen of an aging adult*. Which of these statements regarding the aging adult and abdominal assessment is true?

B) The abdominal musculature is thinner.

12. The nurse is listening to *bowel sounds*. Which of these statements is true of bowel sounds?

B) They are usually high-pitched, gurgling, irregular sounds.

17. An older patient has been diagnosed with *pernicious anemia*. The nurse knows that this condition could be related to:

B) decreased gastric acid secretion.

20. The nurse knows that during an abdominal assessment, *deep palpation* is used to determine:

B) enlarged organs.

39. 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:

B) examine the tender area last.

10. A patient has *hypoactive bowel sounds*. The nurse knows that a potential cause of hypoactive bowel sounds is:

B) peritonitis.

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:

B) pyrosis.

26. The nurse is reviewing the *assessment of an aortic aneurysm*. Which of these statements is true regarding an aortic aneurysm?

C) A pulsating mass is usually present.

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?

C) Appendix

40. During a health history, the patient tells the nurse, "*I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again*!" The nurse suspects that the patient has which condition, based on these symptoms?

C) Duodenal ulcer

16. The nurse is performing *percussion during an abdominal assessment*. Percussion notes heard during the abdominal assessment may include:

C) tympany, hyperresonance, and dullness.

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 handlebars. The nurse suspects that he may have *injured his spleen*. Which of these statements is true regarding assessment of the spleen in this situation?

D) An enlarged spleen should not be palpated because it can rupture easily.

35. The nurse is assessing a patient for possible *peptic ulcer disease* and knows that which condition often causes this problem?

D) Frequent use of nonsteroidal antiinflammatory drugs

4. The nurse suspects that a patient has a *distended bladder*. How should the nurse assess for this condition?

D) Percuss and palpate the midline area above the suprapubic bone.

25. To detect *diastasis recti*, the nurse should have the patient perform which of these maneuvers?

D) Raise the head while remaining supine.

2. Which structure is located in the left lower quadrant of the abdomen?

D) Sigmoid colon

38. During an abdominal assessment, the nurse tests for a *fluid wave. A positive fluid wave *test occurs with:

D) ascites.

8. The nurse is describing a *scaphoid abdomen. To the horizontal plane*, a scaphoid contour of the abdomen depicts a _____ profile.

D) concave

32. 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 about 10 cm*. The nurse should:

D) consider this a normal finding and proceed with the examination.

5. The nurse is aware that one change that may occur in the *gastrointestinal system of an aging adult* is:

D) decreased gastric acid secretion.