NSG 3160 Health Assessment Exam 4
Actual Exam Newest Complete
Questions And Correct Detailed
Answers| Already Graded A+
1. Q: A nurse is preparing to perform an abdominal assessment. In which order
should the nurse perform the techniques?
A: Inspection, auscultation, percussion, palpation.
Rationale: Inspection is always first. Auscultation comes before percussion and
palpation because those techniques can stimulate peristalsis and alter the
frequency of bowel sounds, leading to a false assessment.
2. Q: A patient reports "black, tarry stools" for the past two days. The nurse should
recognize this as:
A: Melena.
Rationale: Melena is the term for black, tarry stools caused by the digestion of
blood in the upper gastrointestinal tract (e.g., stomach, duodenum).
3. Q: A positive psoas sign is elicited when the patient experiences pain during
which maneuver?
A: Flexion of the right hip against resistance while the patient lies supine.
, Rationale: The psoas sign tests for irritation of the iliopsoas muscle, often from
an inflamed appendix. The patient lies supine and lifts the right thigh against the
nurse's hand. Pain indicates a positive sign.
4. Q: A patient presents with right upper quadrant pain that intensifies when the
nurse palpates during inspiration. What sign is this?
A: Murphy's sign.
Rationale: Murphy's sign is tested by hooking the fingers under the liver margin
and asking the patient to take a deep breath. Pain and inspiratory arrest indicate
inflammation of the gallbladder (cholecystitis).
5. Q: Upon auscultation of the abdomen, the nurse hears high-pitched, tinkling
sounds. This finding is most consistent with:
A: Early intestinal obstruction.
Rationale: High-pitched, tinkling sounds suggest fluid and air under tension in a
dilated bowel loop, which is characteristic of early intestinal obstruction.
Hypoactive or absent sounds occur later.
6. Q: Which sound is normally heard when percussing over most of the abdominal
cavity?
A: Tympany.
Rationale: Tympany is the dominant sound heard over abdominal air-filled
structures like the stomach and intestines.
7. Q: During palpation, the nurse identifies a firm, rounded, nontender mass that
descends with inspiration and is located in the left upper quadrant. This is most
likely the:
A: Splenic border (normal spleen).
, Rationale: A normal spleen is sometimes palpable in very thin individuals. It is
located in the left upper quadrant, feels firm and rounded, is nontender, and
moves with respiration.
8. Q: Shifting dullness is a test used to detect:
A: Ascites (free fluid in the peritoneal cavity).
Rationale: To test for shifting dullness, percuss for dullness over a dependent
area. Have the patient roll onto their side. If the fluid shifts, the previously dull
area will become tympanic, and a new area will become dull.
9. Q: A patient complains of severe abdominal pain that is worse upon movement
and causes him to lie perfectly still. The nurse suspects:
A: Peritonitis.
Rationale: Patients with peritonitis (inflammation of the peritoneum) often lie still
because any movement stretches the peritoneum and worsens the pain. They may
also exhibit rigidity and guarding.
10. Q: The nurse asks the patient to raise their head and shoulders while lying flat.
This maneuver is used to differentiate between:
A: A mass in the abdominal wall versus an intra-abdominal mass.
Rationale: When the patient tenses the abdominal muscles, an abdominal wall
mass will remain palpable and may become more prominent, while an intra-
abdominal mass will become harder to feel.
11. Q: A patient with liver dysfunction presents with a protruding abdomen. A
wave of fluid is felt when the nurse taps one side of the abdomen while feeling on
the other. This is a positive test for:
A: Fluid wave (ascites).
Actual Exam Newest Complete
Questions And Correct Detailed
Answers| Already Graded A+
1. Q: A nurse is preparing to perform an abdominal assessment. In which order
should the nurse perform the techniques?
A: Inspection, auscultation, percussion, palpation.
Rationale: Inspection is always first. Auscultation comes before percussion and
palpation because those techniques can stimulate peristalsis and alter the
frequency of bowel sounds, leading to a false assessment.
2. Q: A patient reports "black, tarry stools" for the past two days. The nurse should
recognize this as:
A: Melena.
Rationale: Melena is the term for black, tarry stools caused by the digestion of
blood in the upper gastrointestinal tract (e.g., stomach, duodenum).
3. Q: A positive psoas sign is elicited when the patient experiences pain during
which maneuver?
A: Flexion of the right hip against resistance while the patient lies supine.
, Rationale: The psoas sign tests for irritation of the iliopsoas muscle, often from
an inflamed appendix. The patient lies supine and lifts the right thigh against the
nurse's hand. Pain indicates a positive sign.
4. Q: A patient presents with right upper quadrant pain that intensifies when the
nurse palpates during inspiration. What sign is this?
A: Murphy's sign.
Rationale: Murphy's sign is tested by hooking the fingers under the liver margin
and asking the patient to take a deep breath. Pain and inspiratory arrest indicate
inflammation of the gallbladder (cholecystitis).
5. Q: Upon auscultation of the abdomen, the nurse hears high-pitched, tinkling
sounds. This finding is most consistent with:
A: Early intestinal obstruction.
Rationale: High-pitched, tinkling sounds suggest fluid and air under tension in a
dilated bowel loop, which is characteristic of early intestinal obstruction.
Hypoactive or absent sounds occur later.
6. Q: Which sound is normally heard when percussing over most of the abdominal
cavity?
A: Tympany.
Rationale: Tympany is the dominant sound heard over abdominal air-filled
structures like the stomach and intestines.
7. Q: During palpation, the nurse identifies a firm, rounded, nontender mass that
descends with inspiration and is located in the left upper quadrant. This is most
likely the:
A: Splenic border (normal spleen).
, Rationale: A normal spleen is sometimes palpable in very thin individuals. It is
located in the left upper quadrant, feels firm and rounded, is nontender, and
moves with respiration.
8. Q: Shifting dullness is a test used to detect:
A: Ascites (free fluid in the peritoneal cavity).
Rationale: To test for shifting dullness, percuss for dullness over a dependent
area. Have the patient roll onto their side. If the fluid shifts, the previously dull
area will become tympanic, and a new area will become dull.
9. Q: A patient complains of severe abdominal pain that is worse upon movement
and causes him to lie perfectly still. The nurse suspects:
A: Peritonitis.
Rationale: Patients with peritonitis (inflammation of the peritoneum) often lie still
because any movement stretches the peritoneum and worsens the pain. They may
also exhibit rigidity and guarding.
10. Q: The nurse asks the patient to raise their head and shoulders while lying flat.
This maneuver is used to differentiate between:
A: A mass in the abdominal wall versus an intra-abdominal mass.
Rationale: When the patient tenses the abdominal muscles, an abdominal wall
mass will remain palpable and may become more prominent, while an intra-
abdominal mass will become harder to feel.
11. Q: A patient with liver dysfunction presents with a protruding abdomen. A
wave of fluid is felt when the nurse taps one side of the abdomen while feeling on
the other. This is a positive test for:
A: Fluid wave (ascites).
