NSG3160 | NSG3160 Health Assessment Exam 4
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. Which of the following describes the correct sequence for performing an abdominal
assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Percussion, Palpation
C. Percussion, Auscultation, Inspection, Palpation
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Expert Explanation: The correct sequence for abdominal assessment is inspection,
auscultation, percussion, and palpation. This specific order is followed to avoid
stimulating bowel sounds through physical manipulation before listening.
Auscultating immediately after inspection provides the most accurate clinical
representation of intestinal activity. Palpation and percussion are performed last as
they can cause discomfort or alter findings. Nurses must adhere to this sequence to
ensure the integrity of the gastrointestinal assessment.
2. To determine that bowel sounds are truly absent, the nurse must listen in each
quadrant for at least:
A. 1 minute
,B. 5 minutes
C. 2 minutes
D. 30 seconds
Correct Answer: B
Expert Explanation: Absent bowel sounds are a significant clinical finding that may
indicate a paralytic ileus or bowel obstruction. To confirm this finding, the nurse
must auscultate for a full five minutes before documenting that sounds are missing.
Listening for shorter periods may result in a false-negative assessment of bowel
motility. This protocol ensures patient safety by preventing the oversight of
potential surgical emergencies. Continuous monitoring is required if the patient
exhibits accompanying symptoms like pain or vomiting.
3. Which organs are primarily located in the Right Upper Quadrant (RUQ) of the
abdomen?
A. Liver and Gallbladder
B. Stomach and Spleen
C. Appendix and Cecum
D. Sigmoid colon and Left Ovary
Correct Answer: A
,Expert Explanation: The Right Upper Quadrant primarily contains the liver, the
gallbladder, and the head of the pancreas. Understanding anatomical landmarks is
essential for the nurse to identify the source of patient pain. During percussion and
palpation, the nurse should expect to feel the liver border in this region.
Displacement or enlargement of these organs can signal underlying hepatic or
biliary disease. Knowledge of quadrant contents allows for accurate clinical
reasoning and documentation of findings.
4. A nurse notes a positive Blumberg sign during an assessment. This finding is
associated with which condition?
A. Liver enlargement
B. Kidney stones
C. Peritoneal irritation or appendicitis
D. Gallbladder inflammation
Correct Answer: C
Expert Explanation: The Blumberg sign is also known as rebound tenderness and
is a clinical indicator of peritonitis. It is elicited by applying deep pressure to the
abdomen and then releasing it quickly. Pain that is more intense upon release than
during initial pressure suggests inflammation of the peritoneum. This finding is
frequently associated with acute appendicitis or other intra-abdominal
, emergencies. Immediate communication with the surgical team is often required
when this sign is present.
5. What percussion sound is expected when assessing over a healthy liver?
A. Tympany
B. Hyperresonance
C. Dullness
D. Resonance
Correct Answer: C
Expert Explanation: Dullness is the characteristic sound heard when percussing
over solid organs such as the liver or a full bladder. This sound differs from
tympany, which is heard over air-filled structures like the stomach. Mapping the
area of dullness allows the nurse to estimate the liver’s size and span. A shift in the
location of dullness could indicate organ displacement or hepatomegaly. Mastering
percussion technique is vital for detecting subtle changes in abdominal organ
density.
6. Which technique is specifically used to assess for the presence of ascites?
A. Murphy sign
B. McBurney point palpation
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. Which of the following describes the correct sequence for performing an abdominal
assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Percussion, Palpation
C. Percussion, Auscultation, Inspection, Palpation
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Expert Explanation: The correct sequence for abdominal assessment is inspection,
auscultation, percussion, and palpation. This specific order is followed to avoid
stimulating bowel sounds through physical manipulation before listening.
Auscultating immediately after inspection provides the most accurate clinical
representation of intestinal activity. Palpation and percussion are performed last as
they can cause discomfort or alter findings. Nurses must adhere to this sequence to
ensure the integrity of the gastrointestinal assessment.
2. To determine that bowel sounds are truly absent, the nurse must listen in each
quadrant for at least:
A. 1 minute
,B. 5 minutes
C. 2 minutes
D. 30 seconds
Correct Answer: B
Expert Explanation: Absent bowel sounds are a significant clinical finding that may
indicate a paralytic ileus or bowel obstruction. To confirm this finding, the nurse
must auscultate for a full five minutes before documenting that sounds are missing.
Listening for shorter periods may result in a false-negative assessment of bowel
motility. This protocol ensures patient safety by preventing the oversight of
potential surgical emergencies. Continuous monitoring is required if the patient
exhibits accompanying symptoms like pain or vomiting.
3. Which organs are primarily located in the Right Upper Quadrant (RUQ) of the
abdomen?
A. Liver and Gallbladder
B. Stomach and Spleen
C. Appendix and Cecum
D. Sigmoid colon and Left Ovary
Correct Answer: A
,Expert Explanation: The Right Upper Quadrant primarily contains the liver, the
gallbladder, and the head of the pancreas. Understanding anatomical landmarks is
essential for the nurse to identify the source of patient pain. During percussion and
palpation, the nurse should expect to feel the liver border in this region.
Displacement or enlargement of these organs can signal underlying hepatic or
biliary disease. Knowledge of quadrant contents allows for accurate clinical
reasoning and documentation of findings.
4. A nurse notes a positive Blumberg sign during an assessment. This finding is
associated with which condition?
A. Liver enlargement
B. Kidney stones
C. Peritoneal irritation or appendicitis
D. Gallbladder inflammation
Correct Answer: C
Expert Explanation: The Blumberg sign is also known as rebound tenderness and
is a clinical indicator of peritonitis. It is elicited by applying deep pressure to the
abdomen and then releasing it quickly. Pain that is more intense upon release than
during initial pressure suggests inflammation of the peritoneum. This finding is
frequently associated with acute appendicitis or other intra-abdominal
, emergencies. Immediate communication with the surgical team is often required
when this sign is present.
5. What percussion sound is expected when assessing over a healthy liver?
A. Tympany
B. Hyperresonance
C. Dullness
D. Resonance
Correct Answer: C
Expert Explanation: Dullness is the characteristic sound heard when percussing
over solid organs such as the liver or a full bladder. This sound differs from
tympany, which is heard over air-filled structures like the stomach. Mapping the
area of dullness allows the nurse to estimate the liver’s size and span. A shift in the
location of dullness could indicate organ displacement or hepatomegaly. Mastering
percussion technique is vital for detecting subtle changes in abdominal organ
density.
6. Which technique is specifically used to assess for the presence of ascites?
A. Murphy sign
B. McBurney point palpation
