NUR 210 final exam || All Accurately Answered.
infection correct answers While assessing a client's abdomen, the nurse observes involuntary
reflex guarding on expiration. The nurse would interpret this as most likely indicating what
complication?
An increase in the pitch correct answers Which change in auscultation of bowel sounds should
the nurse recognize as most diagnostic of an intestinal obstruction?
Ask the client to breathe slowly and deeply correct answers The nurse is performing light
palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this
phase of assessment?
ureteral stone correct answers Linda is a 29-year-old who had excruciating pain that started
under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and
then into her right lower quadrant. Which is most likely given this presentation?
"I should avoid lifting heavy objects." correct answers The nurse provides teaching to a client
with gastroesophageal reflux disease (GERD). Which client statement indicates that teaching has
been effective?
Renal calculi
Kidney infection
Hydronephrosis correct answers A client expresses pain when the left costovertebral angle is
palpated. What should the nurse suspect is occurring with this client? Select all that apply.
Cullen's sign correct answers A nurse suspects intra-abdominal bleeding in a client who was
recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to
this suspicion?
,absent correct answers A young adult male who comes to the emergency department complaining
of abdominal pain for the past 3 days is suspected of having a ruptured appendix. What bowel
sound would the nurse expect to assess in this client?
Question the order as a barium enema is contraindicated in acute appendicitis correct answers
The client with a acute appendicitis has been ordered a barium enema. What should the nurse do
first?
Ovarian tumor
Impacted colon
Uterine enlargement
Full bladder correct answers A nurse observes the abdomen of a client and notices it to be
distended below the umbilicus. The nurse recognizes that this can be caused by which of these
conditions? Select all that apply.
Esophageal varices correct answers A 46-year-old former salesman presents to the ER
complaining of black stools for the past few weeks. His past medical history is significant for
cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two
packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day
for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He
is currently unemployed and has never been married. Examination shows a man appearing older
than his stated age. His skin has a yellowish tint and he is thin with a prominent abdomen.
Multiple "spider angiomas" are at the base of his neck. Otherwise his heart and lung
examinations are normal. On inspection he has dilated veins around his umbilicus. Increased
bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more
severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid
wave. He is positive for occult blood on his rectal examination. What cause of black stools most
likely describes his symptoms and signs?
Gastroesophageal reflux correct answers 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?
,Ascites correct answers The nurse has the client participate in the assessment technique shown.
For which health problem is the nurse assessing in this client?
Right side-lying correct answers A nurse is preparing to palpate a client's spleen. Which position
should the nurse use to best facilitate palpation?
Acute pancreatitis correct answers The client has epigastric pain that is poorly localized and
radiates to the back. What would be an important diagnosis to assess for?
Stop the palpation and notify the health care provider correct answers A nurse performs light
palpation of the abdomen and feels a prominent, non-tender, pulsating mass above the umbilicus
that measures approximately six (6) centimeters. What is an appropriate action by the nurse?
Murphy's sign correct answers 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?
Bowel sounds normal correct answers When conducting the physical examination of a client's
abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following
statements would accurately describe this finding?
Gastric ulcer correct answers A client complains of epigastric pain and tarry stools. The nurse
should suspect which of the following as the underlying cause?
Irritable bowel syndrome correct answers Monique is a 33-year-old administrative assistant who
has had intermittent lower abdominal pain approximately one week a month for the past year. It
is not related to her menses. She notes relief with defecation, and a change in form and frequency
of her bowel movements with these episodes. Which of the following is most likely?
, Sickle cell anemia correct answers A shift report indicates that an African American client has
symptoms of both jaundice and splenomegaly. Considering the client's ethnicity and diagnoses,
what is the likely medical diagnosis?
"Do you take painkillers like aspirin on a regular basis?" correct answers A client exhibits many
of the most common signs and symptoms of peptic ulcer disease. What interview question
addresses the most plausible cause of the client's health problem?
Constipation related to decrease in fluid intake correct answers 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?
body mass index greater than 30
taking multiple medications
hiatal hernia correct answers A nurse suspects that a client has gastroesophageal reflux disease
(GERD). Which risk factors must be present for the nurse to confirm this? Select all that apply.
Right upper quadrant
Costovertebral angles
Epigastrium correct answers The nurse is admitting a client who is in hypertensive crisis. The
doctor's notes indicate that bruits that are both systolic and diastolic have been noted and renal
artery stenosis is suspected as the cause of the hypertension. Where would the nurse auscultate
the client's abdomen to hear these bruits? (Select all that apply.)
3 correct answers A client is able to actively move the right arm against gravity. How should the
nurse document this finding using the muscle strength grading scale?
Flexion
infection correct answers While assessing a client's abdomen, the nurse observes involuntary
reflex guarding on expiration. The nurse would interpret this as most likely indicating what
complication?
An increase in the pitch correct answers Which change in auscultation of bowel sounds should
the nurse recognize as most diagnostic of an intestinal obstruction?
Ask the client to breathe slowly and deeply correct answers The nurse is performing light
palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this
phase of assessment?
ureteral stone correct answers Linda is a 29-year-old who had excruciating pain that started
under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and
then into her right lower quadrant. Which is most likely given this presentation?
"I should avoid lifting heavy objects." correct answers The nurse provides teaching to a client
with gastroesophageal reflux disease (GERD). Which client statement indicates that teaching has
been effective?
Renal calculi
Kidney infection
Hydronephrosis correct answers A client expresses pain when the left costovertebral angle is
palpated. What should the nurse suspect is occurring with this client? Select all that apply.
Cullen's sign correct answers A nurse suspects intra-abdominal bleeding in a client who was
recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to
this suspicion?
,absent correct answers A young adult male who comes to the emergency department complaining
of abdominal pain for the past 3 days is suspected of having a ruptured appendix. What bowel
sound would the nurse expect to assess in this client?
Question the order as a barium enema is contraindicated in acute appendicitis correct answers
The client with a acute appendicitis has been ordered a barium enema. What should the nurse do
first?
Ovarian tumor
Impacted colon
Uterine enlargement
Full bladder correct answers A nurse observes the abdomen of a client and notices it to be
distended below the umbilicus. The nurse recognizes that this can be caused by which of these
conditions? Select all that apply.
Esophageal varices correct answers A 46-year-old former salesman presents to the ER
complaining of black stools for the past few weeks. His past medical history is significant for
cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two
packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day
for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He
is currently unemployed and has never been married. Examination shows a man appearing older
than his stated age. His skin has a yellowish tint and he is thin with a prominent abdomen.
Multiple "spider angiomas" are at the base of his neck. Otherwise his heart and lung
examinations are normal. On inspection he has dilated veins around his umbilicus. Increased
bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more
severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid
wave. He is positive for occult blood on his rectal examination. What cause of black stools most
likely describes his symptoms and signs?
Gastroesophageal reflux correct answers 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?
,Ascites correct answers The nurse has the client participate in the assessment technique shown.
For which health problem is the nurse assessing in this client?
Right side-lying correct answers A nurse is preparing to palpate a client's spleen. Which position
should the nurse use to best facilitate palpation?
Acute pancreatitis correct answers The client has epigastric pain that is poorly localized and
radiates to the back. What would be an important diagnosis to assess for?
Stop the palpation and notify the health care provider correct answers A nurse performs light
palpation of the abdomen and feels a prominent, non-tender, pulsating mass above the umbilicus
that measures approximately six (6) centimeters. What is an appropriate action by the nurse?
Murphy's sign correct answers 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?
Bowel sounds normal correct answers When conducting the physical examination of a client's
abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following
statements would accurately describe this finding?
Gastric ulcer correct answers A client complains of epigastric pain and tarry stools. The nurse
should suspect which of the following as the underlying cause?
Irritable bowel syndrome correct answers Monique is a 33-year-old administrative assistant who
has had intermittent lower abdominal pain approximately one week a month for the past year. It
is not related to her menses. She notes relief with defecation, and a change in form and frequency
of her bowel movements with these episodes. Which of the following is most likely?
, Sickle cell anemia correct answers A shift report indicates that an African American client has
symptoms of both jaundice and splenomegaly. Considering the client's ethnicity and diagnoses,
what is the likely medical diagnosis?
"Do you take painkillers like aspirin on a regular basis?" correct answers A client exhibits many
of the most common signs and symptoms of peptic ulcer disease. What interview question
addresses the most plausible cause of the client's health problem?
Constipation related to decrease in fluid intake correct answers 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?
body mass index greater than 30
taking multiple medications
hiatal hernia correct answers A nurse suspects that a client has gastroesophageal reflux disease
(GERD). Which risk factors must be present for the nurse to confirm this? Select all that apply.
Right upper quadrant
Costovertebral angles
Epigastrium correct answers The nurse is admitting a client who is in hypertensive crisis. The
doctor's notes indicate that bruits that are both systolic and diastolic have been noted and renal
artery stenosis is suspected as the cause of the hypertension. Where would the nurse auscultate
the client's abdomen to hear these bruits? (Select all that apply.)
3 correct answers A client is able to actively move the right arm against gravity. How should the
nurse document this finding using the muscle strength grading scale?
Flexion
