Ch. 18 Health Assessment Lungs and Thorax, Assessing the Heart, Abdomen Assessment

A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining if this client is truly experiencing an alteration in bowel pattern? a) "Have you changed your food intake this week?" b) "How many times a day are you having a bowel movement?" c) "What is the consistency of your stools??" d) "Do you have a bowel movement every day?"

"How many times a day are you having a bowel movement?" Explanation: Diarrhea is defined as frequency of bowel movements producing unformed or liquid stools. To determine if the client is truly experiencing diarrhea, the nurse should ask about how many times a day the client is having a bowel movement. The other important question is how many times a day does the client normally have a bowel movement. The consistency will not tell the nurse whether this is normal or abnormal. Asking about food intake will give information about whether the client has tried to treat the problem

A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regards to this finding? a) "How many times have you been pregnant?" b) "Do you have high blood pressure?" c) "Have you noticed any color change to the skin?" d) "Are you experiencing any abdominal pain?"

"How many times have you been pregnant?" Explanation: Striae are silvery white marks that are common on the abdomen from stretching of the skin during pregnancy or weight gain. They do not cause pain or any other color changes to the skin. High blood pressure may cause the dilation of the superficial arterioles or capillaries with a central star pattern (spider angioma) but would not result in striae.

A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says a) "I should cut down on the number of iron tablets I am taking each day." b) "Constipation should decrease if I take the iron tablets with milk." c) "I can decrease the constipation if I eat foods high in fiber and drink water." d) "I should discontinue the iron tablets and eat foods that are high in iron."

"I can decrease the constipation if I eat foods high in fiber and drink water." Explanation: High iron intake may lead to chronic constipation. Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 479.

15. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: a. Dullness. b. Tympany. c. Resonance. d. Hyperresonance.

ANS: A A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor.

29. A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough, and diminished breath sounds

ANS: A A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia (see Table 18-8).

25. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: a. Asthma. b. Atelectasis. c. Lobar pneumonia. d. Heart failure.

ANS: A Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma. (See Table 18-8 for descriptions of the other conditions.)

16. During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? a. When the bronchial tree is obstructed b. When adventitious sounds are present c. In conjunction with whispered pectoriloquy d. In conditions of consolidation, such as pneumonia

ANS: A Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.

32. During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways? a. Listening to at least one full respiration in each location b. Listening as the patient inhales and then going to the next site during exhalation c. Instructing the patient to breathe in and out rapidly while listening to the breath sounds d. If the patient is modest, listening to sounds over his or her clothing or hospital gown

ANS: A During auscultation of breath sounds with a stethoscope, listening to one full respiration in each location is important. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.

9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae b. Third intercostal space, MCL c. Fifth intercostal space, midaxillary line (MAL) d. Over the lower lobes, posterior side

ANS: A Normally, fremitus is most prominent between the scapulae and around the sternum. These sites are where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progresses down the chest because more tissue impedes sound transmission.

35. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: a. Atelectatic crackles that do not have a pathologic cause. b. Fine crackles and may be a sign of pneumonia. c. Vesicular breath sounds. d. Fine wheezes.

ANS: A One type of adventitious sound, atelectatic crackles, does not have a pathologic cause. They are short, popping, crackling sounds that sound similar to fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

12. The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. a. Side-to-side b. Top-to-bottom c. Posterior-to-anterior d. Interspace-by-interspace

ANS: A Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are not correct.

3. When assessing a patient's lungs, the nurse recalls that the left lung: a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach.

ANS: A The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobes.

7. The primary muscles of respiration include the: a. Diaphragm and intercostals. b. Sternomastoids and scaleni. c. Trapezii and rectus abdominis. d. External obliques and pectoralis major.

ANS: A The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles—sternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles.

1. Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: a. The spinous process of C7. b. Usually nonpalpable in most individuals. c. Opposite the interior border of the scapula. d. Located next to the manubrium of the sternum.

ANS: A The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

22. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchial sounds c. Bronchophony d. Whispered pectoriloquy

ANS: A Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

20. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a. Airway obstruction b. Emphysema c. Pulmonary consolidation d. Asthma

ANS: C Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony (see Table 18-7).

38. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. b. As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. d. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. e. As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.

ANS: A, C, D As a patient repeatedly says "ninety-nine," normally the examiner hears voice sounds but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation, which is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this sound could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiner clearly hears the whispered voice, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

30. A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate: a. Pneumonia. b. Postnasal drip or sinusitis. c. Exposure to irritants at work. d. Chronic bronchial irritation from smoking.

ANS: B A cough that primarily occurs at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.

37. A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Crackles d. Wheezing

ANS: B A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with pneumonia, heart failure, chronic bronchitis, and other diseases (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

34. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: a. Tactile fremitus. b. Crepitus. c. Friction rub. d. Adventitious sounds.

ANS: B Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, such as after open thoracic injury or surgery.

4. Which statement about the apices of the lungs is true? The apices of the lungs: a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).

ANS: B The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

17. The nurse knows that a normal finding when assessing the respiratory system of an older adult is: a. Increased thoracic expansion. b. Decreased mobility of the thorax. c. Decreased anteroposterior diameter. d. Bronchovesicular breath sounds throughout the lungs.

ANS: B The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.

5. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: a. Costal angle. b. Sternal angle. c. Xiphoid process. d. Suprasternal notch.

ANS: B The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

19. During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort

ANS: B Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain.

24. A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: a. Bronchitis. b. Pneumothorax. c. Acute pneumonia. d. Asthmatic attack.

ANS: B With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. (See Table 18-8 for descriptions of the other conditions.)

21. The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds a. Musical in quality. b. Usually caused by a pathologic disease. c. Expected near the major airways. d. Similar to bronchial sounds except shorter in duration.

ANS: C Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorly—between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

27. A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? a. "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." b. "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." c. "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." d. "This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother's body, which results in an increased respiratory rate."

ANS: C During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong. Increases in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mother's body, this increased demand is easily met by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

33. A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b. Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness upon percussion

ANS: C Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes.

14. The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b. Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the chest d. Lightly holding the bell of the stethoscope against the chest to avoid friction

ANS: C Firmly holding the diaphragm of the stethoscope against the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.

10. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus: a. "Is caused by moisture in the alveoli." b. "Indicates that air is present in the subcutaneous tissues." c. "Is caused by sounds generated from the larynx." d. "Reflects the blood flow through the pulmonary arteries."

ANS: C Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

36. A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? a. Bradypnea b. Cheyne-Stokes respirations c. Hypoventilation d. Chronic obstructive breathing

ANS: C Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. (See Table 18-4 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.)

6. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: a. Adventitious sounds and limited chest expansion. b. Increased tactile fremitus and dull percussion tones. c. Muffled voice sounds and symmetric tactile fremitus. d. Absent voice sounds and hyperresonant percussion tones.

ANS: C Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

28. A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: a. Bronchitis. b. Pneumonia. c. Tuberculosis. d. Pulmonary edema.

ANS: C Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers (see Table 18-8).

8. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? a. Obtaining a detailed health history of the patient's allergies and a history of asthma b. Telling the patient to sleep on his or her right side to facilitate ease of respirations c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week

ANS: C The patient is experiencing paroxysmal nocturnal dyspnea—being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

2. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest.

ANS: C The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

13. When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: a. Normally auscultated over the trachea. b. Bronchial breath sounds and normal in that location. c. Vesicular breath sounds and normal in that location. d. Bronchovesicular breath sounds and normal in that location.

ANS: C Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where air flows through smaller bronchioles and alveoli.

11. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: a. Shallow breathing. b. Normal lung tissue. c. Decreased adipose tissue. d. Increased density of lung tissue.

ANS: D A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Resonance is the expected finding in normal lung tissue.

23. A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? a. Unequal chest expansion b. Increased tactile fremitus c. Atrophied neck and trapezius muscles d. Anteroposterior-to-transverse diameter ratio of 1:1

ANS: D An anteroposterior-to-transverse diameter ratio of 1:1 or barrel chest is observed in individuals with COPD because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations

26. The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? a. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. b. Respiratory muscle strength increases to compensate for a decreased vital capacity. c. Decrease in small airway closure occurs, leading to problems with atelectasis. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

ANS: D In the aging adult, the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa occurs, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

Nursing students are learning how to identify different areas of the abdomen. What is the lower middle area called? a) Hypogastric b) Hypochondriac c) Inogastric d) Epigastric

Hypogastric Explanation: The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbical, left lumbar, right inguinal, hypogastric, and left inguinal.

18. When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall

ANS: D Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness and the patient's skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

31. During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? a. Croup b. Tuberculosis c. Viral infection d. Pulmonary edema

ANS: D Sputum, alone, is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema or it may be a side effect of sympathomimetic medications. Croup is associated with a barking cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.

Describe the technique for percussing the heart by placing the steps in the correct order.

Identify the third, fourth, and fifth intercostal spaces. Place the middle finger of the nondominant hand on the surface to be percussed. Curve the middle finder of the dominant hand. Starting on the left, use a quick, sharp motion of the wrist and strike the middle finger of the nondominant hand. Strike in one or two areas, then move on. Listen for resonance to dullness.

The nurse is palpating the base of the heart and identifies a fine rushing vibration. The nurse correctly documents this symptom as what?

Murmur

The nurse suspects an abdominal aortic aneurysm when what is assessed? a) Abdominal bruit b) Increased femoral pulses c) Warm extremities d) Hypertension

Abdominal bruit Explanation: Auscultation of the abdomen would reveal a bruit. The client may exhibit decreased femoral pulses, hypotension and cool extremities.

Which of the following assessment findings would need to be reported the physician immediately? a) Absent bowel sounds, vomiting undigested food b) Chest fullness, heartburn and nausea after eating c) Diarrhea and flatus d) Constipation

Absent bowel sounds, vomiting undigested food Explanation: Absent bowel sounds, vomiting undigested food is abnormal and may indicate a bowel obstruction. Constipation, Chest fullness, heartburn and nausea after eating. diarrhea and flatus do are not as high of a priority.

Match the auscultatory landmark with its anatomic location.

Aortic Valve Area- second right intercostal space at the right sternal border Pulmonic Valve Area-second left intercostal space at the left sternal border Second Pulmonic Area(erb's point)-third left intercostal space at the left sternal border Tricuspid Area-fourth left intercostal space along the lower left sternal border Mitral (or Apical) Area- apex of the heart in the fifth left intercostal space at the midclavicular line

The nurse assesses a patient with abnormal heart sounds. This symptom is correctly documented as the third heart sound (S3) because it is low-pitched and located at which area of the heart?

Apex

A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action? a) Ask about pertinent risk factors. b) Document a detailed health history. c) Ask the client when the pain began. d) Obtain a 24 hour diet recall.

Ask the client when the pain began. Explanation: If a patient has an acute abdominal problem, the history and physical examination will be focused on that problem, so that much of the history taking will be eliminated. Severe dehydration from nausea and vomiting, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Pain is the chief complaint and should be assessed before a diet recall, obtaining a health history, and identifying risk factors

A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend? a) Avoid eating overcooked foods b) Avoid taking pain medications with food c) Avoid taking antacid medications d) Avoid excessive alcohol intake

Avoid excessive alcohol intake Explanation: The nurse should recommend avoiding excessive alcohol intake, as this is a risk factor associated with peptic ulcer disease. The nurse should also recommend eating foods that have been cooked completely and taking pain medications with food. Antacid medications may relieve peptic ulcers

While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound? a) Erratic b) Borborygmus c) Hypoactive d) Absent

Borborygmus Explanation: The nurse should find that bowel sounds are absent in a client with paralytic ileus. Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds. Hyperactive bowel sounds may be caused by diarrhea, gastroenteritis, and early bowel obstruction. Hypoactive bowel sounds may be due to surgery or late bowel obstruction. Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling." Erratic is not a type of bowel sound.

When palpating a client's liver, the nurse feels a firm edge. What would this indicate to the nurse? a) Cirrhosis b) Splenomegaly c) Calcification of the liver d) Liver failure

Cirrhosis Explanation: Abnormal liver findings include hepatomegaly and the firm edge of cirrhosis. A firm edge does not indicate liver failure or calcification. Splenomegaly is a distractor for this question.

Identify the area of the body where the nurse observes for lifts and heaves.

Precordium The precordium is the area of the body the nurse would observe for lifts and heaves.

A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client? a) Ineffective Health Maintenance b) Constipation related to decrease in fluid intake c) Risk for Fluid Volume Deficit d) Ineffective Nutrition: Less Than Body Requirements

Constipation related to decrease in fluid intake Explanation: The nurse can confirm constipation because the major defining characteristics of decreased frequency and abdominal discomfort are present. A few days of altered nutrition does not meet the necessary criteria to confirm Ineffective Nutrition or Risk for Fluid Volume Deficit. Ineffective Health Maintenance cannot be confirmed because there is no evidence that the client lacks the knowledge to eat properly

A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? a) Gastric ulcer b) Pancreatitis c) Gastroesophageal reflux d) Crohn's disease

Crohn's disease Explanation: Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine

A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? a) Gastroesophageal reflux b) Crohn's disease c) Pancreatitis d) Gastric ulcer

Crohn's disease Explanation: Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Pancreatitis is worsened with alcohol ingestion. Gastroesophageal reflux is worsened when supine

The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant? a) Rub b) Hollow tympanic notes c) Dullness d) Hum

Dullness Explanation: Normal percussion findings include dullness over the liver in the RUQ and hollow tympanic notes in the LUQ over the gastric bubble. Hums and rubs are ausculatory sounds.

Identify the area where the mitral valve should be auscultated.

Fifth intercostal space at the midclavicular line

On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity? a) Fluid accumulation b) Obstruction c) Inflammation d) Bleeding

Fluid accumulation Explanation: Pale and taut skin indicates significant abdominal swelling caused by accumulation of fluid in the abdominal cavity, or ascites. Bleeding within the abdominal wall would manifest as purple discoloration at the flanks. Inflammation of the peritoneum and obstruction of the intestine does not contribute to pale and taut abdominal skin.

Which of the following people need to be vaccinated for hepatitis A and B? a) Animal care workers b) Food-service workers c) Office personnel d) Truck drivers

Food-service workers Explanation: Hepatitis A and B immunizations are recommended for all infants; people whose work may expose them to blood, body fluids, or unsanitary conditions (i.e., health care, food services, sex workers); and those traveling to parts of the world where these illnesses are prevalent.

A client complains of abdominal pain that is worsened when he lies on his back. The nurse should suspect which of the following as the underlying cause? a) Pancreatitis b) Gastroesophageal reflux c) Gastric ulcer d) Crohn's disease

Gastroesophageal reflux Explanation: Gastroesophageal reflux is worsened when supine. Epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer. Abdominal pain with cramping, diarrhea, nausea, vomiting, weight loss, and lack of energy is often seen in Crohn's disease. Pancreatitis is worsened with alcohol ingestion.

The nurse is having trouble auscultating the apical impulse of an obese patient. Which action by the nurse would improve this assessment?

Have the patient lean forward.

A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause? a) Escherichia coli b) Streptococcus pyogenes c) Staphylococcus aureus d) Helicobacter pylori

Helicobacter pylori Explanation: Often the bacterium Helicobacter pylori (H. pylori) is active in causing the ulcer. Although usually present in the mucous, on occasion the H. pylori disrupt the mucous lining and inflame the organ lining. The other bacteria listed are not associated with peptic ulcer disease

Which is the proper sequence of examination for the abdomen? a) Auscultation, percussion, inspection, palpation b) Inspection, percussion, palpation, auscultation c) Auscultation, inspection, palpation, percussion d) Inspection, auscultation, percussion, palpation

Inspection, auscultation, percussion, palpation Explanation: The abdominal examination is conducted in a sequence different from other systems. Usually the order is inspection, percussion, palpation, then auscultation. Because palpation may actually cause some bowel noise when the bowels are not moving, auscultation is performed before percussion and palpation.

A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following? a) Linea alba b) Peritoneum c) Internal abdominal oblique d) Transverse abdominis

Linea alba Explanation: The joining of the muscle fibers and aponeuroses at the midline of the abdomen forms a white line called the linea alba, which extends vertically from the xiphoid process of the sternum to the symphysis pubis. The abdomen includes three layers of muscle extending from the back, around the flanks, to the front. The outermost layer is the external abdominal oblique; the middle layer is the internal abdominal oblique; and the innermost layer is the transverse abdominis. A thin, shiny, serous membrane called the peritoneum lines the abdominal cavity (parietal peritoneum) and also provides a protective covering for most of the internal abdominal organs (visceral peritoneum).

A nurse auscultates for bowels sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after one minute. What is an appropriate action by the nurse? a) Listen for a total of five (5) minutes b) Document the absence of bowel sounds c) Palpate for abdominal rigidity d) Assess for findings of dehydration

Listen for a total of five (5) minutes Explanation: Bowel sounds normally occur every 5 to 15 seconds. In a client with nausea and vomiting, bowel sounds may be hypoactive. The nurse should listen for a total of 5 minutes to confirm the absence of bowel sounds. Assessing the client for dehydration is necessary but not in relation to the finding of bowel sounds. Palpation should be done after completing auscultation of the abdomen.

Describe how the nurse uses palpation to identify dextrocardia.

Locate the point of maximal impulse (PMI)

The nurse is auscultating heart sounds of a patient with heart-related symptoms. The nurse understands that the bell of the stethoscope is best used for auscultating what heart sounds?

Low-pitched heart sounds

Your patient describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your patient? a) Crohn disease b) Ulcerative colitis c) Lactose intolerance d) Malabsorption syndrome

Malabsorption syndrome Explanation: Malabsorption syndrome is characterized by stool that is typically bulky, soft, light yellow to gray, mushy, greasy or oily, sometimes frothy, and particularly foul-smelling, and it usually floats in the toilet.

A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement? a) Auscultate for bowel sounds b) Measure abdominal girth c) Perform percussion for tympany d) Palpate the abdomen

Measure abdominal girth Explanation: The nurse should measure abdominal girth daily to assess changes in abdominal distension. Palpating and auscultating the abdomen may not give relevant information about peritonitis. Percussion for tympany may indicate presence of air but does not indicate improvement.

During the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign? a) Rovsing's b) Obturator c) Psoas d) Murphy's

Murphy's Explanation: Murphy's sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. The obturator sign involves pain in the right lower quadrant as a result of the nurse flexing the client's hip and rotating the leg externally and internally while supporting the client's right knee and ankle. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Rovsing's sign involves pain caused by deep palpation in the left lower quadrant.

Mr. Martin is a 72-year-old smoker who comes to the clinic for a follow-up visit for hypertension. With deep palpation a pulsatile mass about 4 cm in diameter is palpable. What should the examiner do next? a) Refer to a vascular surgeon. b) Reassess by examination in 3 months. c) Reassess by examination in 6 months. d) Obtain abdominal ultrasound.

Obtain abdominal ultrasound. Explanation: A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 cm. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature.

While inspecting the chest, the nurse observes unusual chest movements. Which assessment technique should the nurse perform next?

Palpation Palpation of the chest for lifts and heaves would follow the observation of unusual chest movements.

When auscultating the heart sounds, the nurse makes note of what qualities of the auscultated sounds?

Pitch, rhythm, location, timing

Put the steps the nurse uses to locate the point of maximal impulse (PMI) in the correct order.

Place patient in supine position.Stand on patient's right side.Gently place palmar surface of fingers at the apex of the heart.Have patient turn slightly to left side if unable to locate pulsation with patient in supine position.Have a female patient displace her left breast to the side.

Describe how the nurse uses palpation to ensure the identification of the first heart sound (S1).

Placing the hand over the carotid artery and point of maximal impulse (PMI) By simultaneously placing fingers of one hand over the carotid artery and fingers of the other hand over the PMI, the nurse can identify when the first heart sound (S1) occurs. The beat of S1 and pulsation of the carotid artery occur synchronously.

The nurse correctly identifies the gallbladder is located where? a) RUQ b) RLQ c) LUQ d) LLQ

RUQ The gallbladder is located in the right upper quadrant of the abdomen. Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 23: Assessing Abdomen, pg. 475.

A client complains of a sudden onset of pain in the back. On questioning the client further, the nurse learns that the cause of the pain is acute pancreatitis. The nurse recognizes that this type of pain is which of the following? a) Referred pain b) Radiated pain c) Chronic pain d) Localized pain

Referred pain Explanation: Pancreatic inflammation, or pancreatitis, may be felt in the back. This is called "referred" pain because the pain is not felt at its source. This is not radiated pain, which extends continuously to the tissues surrounding the source, nor is it localized pain, which remains only in one small area. It is not chronic pain, as it results from acute pancreatitis.

Using percussion, the nurse identifies the cardiac border by a change from a _____ to a _____ note.

Resonant; dull

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? a) Right lower quadrant b) Left lower quadrant c) Right upper quadrant d) Left upper quadrant

Right upper quadrant Explanation: The liver is the largest solid organ in the body. It is located below the diaphragm in the right upper quadrant of the abdomen.

Which nursing diagnosis is most appropriate for an elderly client with poor dentition? a) Risk for Imbalanced Nutrition: Less Than Body Requirements b) Constipation c) Diarrhea d) Fluid volume deficit

Risk for Imbalanced Nutrition: Less Than Body Requirements Explanation: A client with poor dentition is at risk for Imbalanced Nutrition: Less Than Body Requirements as teeth may be missing or chewing may be difficult. None of the other diagnosis are related to poor dentition.

The nurse is caring for a client suffering from a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part? a) Oropharynx b) Descending colon c) Small intestine d) Esophagus

Small intestine Explanation: Absorption of nutrients takes place almost exclusively in the small intestine. The esophagus propels the food bolus by means of slow peristaltic movements into the stomach. The descending colon is part of the large intestine. Mastication occurs in the mouth, then food moves into the oropharynx and esophagus for food propulsion through the digestive tract.

A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ? a) Kidney b) Spleen c) Liver d) Gall bladder

Spleen Explanation: Percussion of the spleen begins in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness. Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage and striking it with the ulnar side of the right fist. The costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a kidney problem such as infection (pyelonephritis), renal calculi, or hydronephrosis. The gall bladder is not percussed.

The nurse understands this abdominal organ is responsible for storing red blood cells and platelets. a) Spleen b) Gallbladder c) Pancreas d) Liver

Spleen Explanation: The spleen stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The pancreas is responsible the secretion of insulin, amylase and lipase. The liver produces and secretes bile. The gallbladder stores bile.

The nurse percusses the lowest interface in the left anterior axillary line, asks the client to take a deep breath, and percusses again. The nurse is assessing for which of the following? a) Splenic percussion sign b) Kidney tenderness c) Tenderness of a nonpalpable liver d) Diaphragmatic displacement

Splenic percussion sign Explanation: A change in the percussion note from tympany to dullness on inspiration in this location suggests splenic enlargement. The given procedure is the correct technique for assessing for a positive splenic percussion sign, not kidney tenderness, liver palpation, or diaphragmatic displacement.

When inspecting the abdomen, which of the following client positions facilitates correct examination technique? a) Trendelenberg with hands over head b) Semi-Fowler's with pillows under head and knees c) Sitting with hands on hips d) Supine with arms at sides or folded across chest

Supine with arms at sides or folded across chest Explanation: A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenberg, or semi-Fowler's position.

Which of the following statements provides the most accurate guide to the assessment of the gallbladder? a) The gallbladder should be percussed and palpated prior to the liver to avoid confusing it with the larger organ. b) The margins of the gallbladder are obscured by the spleen. c) Cholecystitis and cholelithiasis are not amenable to diagnosis in the clinical setting. d) The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Explanation: Because the gallbladder is deep to the liver, it is normally not amenable to direct examination by auscultation, palpation, or percussion. This does not mean, however, that cholecystitis and cholelithiasis cannot be assessed for a thorough history. The gallbladder and the spleen are not proximate.

Which statement describes the limitations of using the percussion technique in physical examination

The heart conforms to the chest's shape, making it difficult to assess heart size. Fluid or air can distort findings.

Why is it vital to identify the baseline rate and rhythm of the heart?

To identify tachycardia or bradycardia. To identify dysrhythmias

When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach. a) False b) True

True Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 495.

Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites? a) Bilateral flank tympany b) Tympany that changes location with client position c) Dullness centrally when the client is supine d) Dullness that remains despite change in position

Tympany that changes location with client position Explanation: A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float, so dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany that changes location with client position ("shifting dullness") would support the presence of ascites. A fluid wave and edema would support this diagnosis as well. (l

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should a) place the client in a side-lying position. b) ask the client to empty his bladder. c) ask the client to hold his breath for a few seconds. d) tell the client to raise his arms above his head.

ask the client to empty his bladder. Explanation: Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination.

The pancreas of an adult client is located a) high and deep under the diaphragm and can be palpated. b) posterior to the left midaxillary line and posterior to the stomach. c) below the diaphragm and extending below the right costal margin. d) deep in the upper abdomen and is not normally palpable.

deep in the upper abdomen and is not normally palpable. Explanation: The pancreas, located mostly behind the stomach deep in the upper abdomen, is normally not palpable. It is a long gland extending across the abdomen from the RUQ to the LUQ.

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible a) liver disease. b) abdominal distention. c) internal bleeding. d) Cushing syndrome.

internal bleeding. Explanation: Purple discoloration at the flanks (Grey-Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the a) right upper quadrant. b) left upper quadrant. c) right lower quadrant. d) left lower quadrant.

left upper quadrant. Explanation: The spleen is located in the left upper quadrant. Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 474.

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the a) left lower quadrant. b) right lower quadrant. c) right upper quadrant. d) left upper quadrant.

left upper quadrant. Explanation: The spleen is located in the left upper quadrant. Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 474

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible a) masses. b) cachexia. c) gallbladder disease. d) kidney trauma.

masses. Explanation: A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue.

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? a) right lower b) right upper c) left upper d) left lower

right upper Explanation: The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal.

A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of a) stomach ulcers. b) pancreatic cancer. c) abdominal tumors. d) decreased gastric motility.

stomach ulcers. Explanation: Vomiting with blood (hematemesis) is seen with esophageal varices or duodenal ulcers. Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 478.

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should a) palpate the abdomen before auscultation. b) listen in each quadrant for 15 seconds. c) begin auscultation in the left upper quadrant. d) use the diaphragm of the stethoscope.

use the diaphragm of the stethoscope. Explanation: Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client's abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants