NSG 3160 EXAM 4 (GALEN) NEWEST ACTUAL EXAM TEST BANK |
HEALTH ASSESSMENT EXAM 4
QUESTIONS & CORRECT ANSWER💜💜S WITH RATIONALES
1. A nurse is preparing to perform an abdominal assessment on a patient. In which order should the
nurse perform the techniques?
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, percussion, palpation
D. Palpation, percussion, auscultation, inspection
Correct Answer💜💜: B. Inspection, auscultation, percussion, palpation
Rationale: The order of abdominal assessment differs from other body systems because palpation and
percussion can stimulate peristalsis, which would alter the frequency and intensity of bowel sounds. The
correct sequence is inspection (to observe surface characteristics), then auscultation (to listen to
undisturbed bowel sounds), followed by percussion, and finally palpation .
2. While auscultating a patient's abdomen, the nurse hears high-pitched, tinkling sounds every 3-4
seconds. How should the nurse document this finding?
A. Hypoactive bowel sounds
B. Normal bowel sounds
C. Hyperactive bowel sounds
D. Absent bowel sounds
Correct Answer💜💜: B. Normal bowel sounds
*Rationale: Normal bowel sounds are high-pitched, gurgling, or clicking sounds that occur approximately
5-35 times per minute, typically every 5-15 seconds. Descriptors like "high-pitched" or "tinkling" are
,often within normal range unless accompanied by other symptoms. Hyperactive bowel sounds are
louder, more frequent, and may be heard without a stethoscope. Hypoactive refers to diminished
frequency, and absent means no sounds after 3-5 minutes of auscultation .*
3. A nurse notes visible peristaltic waves moving from left to right across a patient's upper abdomen.
This finding is most suggestive of:
A. Intestinal obstruction
B. Normal variation in thin patients
C. Ascites
D. Gastric ulcer
Correct Answer💜💜: A. Intestinal obstruction
Rationale: Visible peristalsis is usually not seen in healthy adults due to the thickness of the abdominal
wall. When visible, it often indicates intestinal obstruction, where the bowel works vigorously against the
blockage. While sometimes visible in very thin individuals, it should raise suspicion for pathology,
especially if accompanied by pain or distension .
4. A patient reports having "black, tarry stools" for the past two days. The nurse should recognize this
as:
A. Steatorrhea
B. Melena
C. Hematochezia
D. Occult blood
Correct Answer💜💜: B. Melena
Rationale: Melena describes black, tarry, foul-smelling stools caused by the oxidation of hemoglobin to
hematin as blood passes through the intestinal tract. This typically indicates bleeding from the upper
gastrointestinal tract (esophagus, stomach, or duodenum). Hematochezia is bright red blood per rectum,
usually from lower GI bleeding. Steatorrhea is fatty, foul-smelling stool from malabsorption .
,5. During palpation of the abdomen, the nurse notes a large, pulsating mass in the upper midline.
What is the priority nursing action?
A. Deeply palpate to determine the full extent of the mass
B. Percuss the mass to assess density
C. Stop palpation and assess for bruits with the stethoscope
D. Document the finding as a normal aortic pulsation
Correct Answer💜💜: C. Stop palpation and assess for bruits with the stethoscope
Rationale: A large, pulsating midline mass suggests an abdominal aortic aneurysm (AAA). Deep
palpation is contraindicated as it could precipitate rupture. The nurse should immediately auscultate for
bruits (whooshing sounds indicating turbulent blood flow), check for femoral pulses, and report the
finding to the healthcare provider immediately. This is a potentially life-threatening emergency .
6. The nurse is assessing a patient with suspected liver disease. Which percussion finding would be
most concerning?
A. Tympany in the gastric area
B. Dullness in the right upper quadrant
C. Dullness in the left upper quadrant
D. Shifting dullness in the flanks
Correct Answer💜💜: D. Shifting dullness in the flanks
Rationale: Shifting dullness is a test for ascites (fluid in the peritoneal cavity). When the patient is supine,
fluid settles in the flanks, producing dullness to percussion. When the patient turns to the side, the fluid
shifts, and the area that was previously dull becomes tympanic. This finding is associated with liver
disease, heart failure, or malignancy. Tympany in the gastric area (LUQ) is normal (Traube's space).
Dullness in the RUQ over the liver is expected .
7. A patient presents with complaints of heartburn and regurgitation, especially after meals and when
lying down. The nurse suspects:
A. Peptic ulcer disease
B. Gastritis
, C. Gastroesophageal reflux disease (GERD)
D. Cholecystitis
Correct Answer💜💜: C. Gastroesophageal reflux disease (GERD)
Rationale: The classic symptoms of GERD are pyrosis (heartburn) and regurgitation, which worsen after
meals, when bending over, or when lying down. This occurs due to incompetence of the lower
esophageal sphincter, allowing gastric contents to reflux into the esophagus. Peptic ulcer disease
typically causes gnawing epigastric pain. Cholecystitis presents with RUQ pain, often after fatty meals .
8. The nurse is assessing a patient's abdomen for rebound tenderness. Which technique is correct?
A. Deeply palpate the painful area first
B. Hold the hand perpendicular to the abdomen and press firmly
C. Press slowly and deeply into the abdomen, then quickly release
D. Lightly stroke the abdomen with a cotton applicator
Correct Answer💜💜: C. Press slowly and deeply into the abdomen, then quickly release
Rationale: Rebound tenderness is assessed by pressing slowly and deeply into the abdomen (ideally away
from the painful area first) and then quickly releasing the pressure. Pain upon release indicates
peritoneal irritation (peritonitis). This test should be performed at the end of the examination as it causes
significant discomfort .
9. A positive psoas sign is elicited when the patient experiences pain during which maneuver?
A. Extension of the right thigh while the patient lies on the left side
B. Flexion of the right hip against resistance
C. Rotation of the flexed thigh internally and externally
D. Lying supine and raising both legs straight
Correct Answer💜💜: B. Flexion of the right hip against resistance
Rationale: The psoas sign tests for irritation of the iliopsoas muscle group, often from an inflamed
appendix. The test is positive if the patient experiences abdominal pain when flexing the right hip against
HEALTH ASSESSMENT EXAM 4
QUESTIONS & CORRECT ANSWER💜💜S WITH RATIONALES
1. A nurse is preparing to perform an abdominal assessment on a patient. In which order should the
nurse perform the techniques?
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, percussion, palpation
D. Palpation, percussion, auscultation, inspection
Correct Answer💜💜: B. Inspection, auscultation, percussion, palpation
Rationale: The order of abdominal assessment differs from other body systems because palpation and
percussion can stimulate peristalsis, which would alter the frequency and intensity of bowel sounds. The
correct sequence is inspection (to observe surface characteristics), then auscultation (to listen to
undisturbed bowel sounds), followed by percussion, and finally palpation .
2. While auscultating a patient's abdomen, the nurse hears high-pitched, tinkling sounds every 3-4
seconds. How should the nurse document this finding?
A. Hypoactive bowel sounds
B. Normal bowel sounds
C. Hyperactive bowel sounds
D. Absent bowel sounds
Correct Answer💜💜: B. Normal bowel sounds
*Rationale: Normal bowel sounds are high-pitched, gurgling, or clicking sounds that occur approximately
5-35 times per minute, typically every 5-15 seconds. Descriptors like "high-pitched" or "tinkling" are
,often within normal range unless accompanied by other symptoms. Hyperactive bowel sounds are
louder, more frequent, and may be heard without a stethoscope. Hypoactive refers to diminished
frequency, and absent means no sounds after 3-5 minutes of auscultation .*
3. A nurse notes visible peristaltic waves moving from left to right across a patient's upper abdomen.
This finding is most suggestive of:
A. Intestinal obstruction
B. Normal variation in thin patients
C. Ascites
D. Gastric ulcer
Correct Answer💜💜: A. Intestinal obstruction
Rationale: Visible peristalsis is usually not seen in healthy adults due to the thickness of the abdominal
wall. When visible, it often indicates intestinal obstruction, where the bowel works vigorously against the
blockage. While sometimes visible in very thin individuals, it should raise suspicion for pathology,
especially if accompanied by pain or distension .
4. A patient reports having "black, tarry stools" for the past two days. The nurse should recognize this
as:
A. Steatorrhea
B. Melena
C. Hematochezia
D. Occult blood
Correct Answer💜💜: B. Melena
Rationale: Melena describes black, tarry, foul-smelling stools caused by the oxidation of hemoglobin to
hematin as blood passes through the intestinal tract. This typically indicates bleeding from the upper
gastrointestinal tract (esophagus, stomach, or duodenum). Hematochezia is bright red blood per rectum,
usually from lower GI bleeding. Steatorrhea is fatty, foul-smelling stool from malabsorption .
,5. During palpation of the abdomen, the nurse notes a large, pulsating mass in the upper midline.
What is the priority nursing action?
A. Deeply palpate to determine the full extent of the mass
B. Percuss the mass to assess density
C. Stop palpation and assess for bruits with the stethoscope
D. Document the finding as a normal aortic pulsation
Correct Answer💜💜: C. Stop palpation and assess for bruits with the stethoscope
Rationale: A large, pulsating midline mass suggests an abdominal aortic aneurysm (AAA). Deep
palpation is contraindicated as it could precipitate rupture. The nurse should immediately auscultate for
bruits (whooshing sounds indicating turbulent blood flow), check for femoral pulses, and report the
finding to the healthcare provider immediately. This is a potentially life-threatening emergency .
6. The nurse is assessing a patient with suspected liver disease. Which percussion finding would be
most concerning?
A. Tympany in the gastric area
B. Dullness in the right upper quadrant
C. Dullness in the left upper quadrant
D. Shifting dullness in the flanks
Correct Answer💜💜: D. Shifting dullness in the flanks
Rationale: Shifting dullness is a test for ascites (fluid in the peritoneal cavity). When the patient is supine,
fluid settles in the flanks, producing dullness to percussion. When the patient turns to the side, the fluid
shifts, and the area that was previously dull becomes tympanic. This finding is associated with liver
disease, heart failure, or malignancy. Tympany in the gastric area (LUQ) is normal (Traube's space).
Dullness in the RUQ over the liver is expected .
7. A patient presents with complaints of heartburn and regurgitation, especially after meals and when
lying down. The nurse suspects:
A. Peptic ulcer disease
B. Gastritis
, C. Gastroesophageal reflux disease (GERD)
D. Cholecystitis
Correct Answer💜💜: C. Gastroesophageal reflux disease (GERD)
Rationale: The classic symptoms of GERD are pyrosis (heartburn) and regurgitation, which worsen after
meals, when bending over, or when lying down. This occurs due to incompetence of the lower
esophageal sphincter, allowing gastric contents to reflux into the esophagus. Peptic ulcer disease
typically causes gnawing epigastric pain. Cholecystitis presents with RUQ pain, often after fatty meals .
8. The nurse is assessing a patient's abdomen for rebound tenderness. Which technique is correct?
A. Deeply palpate the painful area first
B. Hold the hand perpendicular to the abdomen and press firmly
C. Press slowly and deeply into the abdomen, then quickly release
D. Lightly stroke the abdomen with a cotton applicator
Correct Answer💜💜: C. Press slowly and deeply into the abdomen, then quickly release
Rationale: Rebound tenderness is assessed by pressing slowly and deeply into the abdomen (ideally away
from the painful area first) and then quickly releasing the pressure. Pain upon release indicates
peritoneal irritation (peritonitis). This test should be performed at the end of the examination as it causes
significant discomfort .
9. A positive psoas sign is elicited when the patient experiences pain during which maneuver?
A. Extension of the right thigh while the patient lies on the left side
B. Flexion of the right hip against resistance
C. Rotation of the flexed thigh internally and externally
D. Lying supine and raising both legs straight
Correct Answer💜💜: B. Flexion of the right hip against resistance
Rationale: The psoas sign tests for irritation of the iliopsoas muscle group, often from an inflamed
appendix. The test is positive if the patient experiences abdominal pain when flexing the right hip against
