NUR 2092 HEALTH ASSESSMENT REVISION
HANDBOOK 2026 HISTORY TAKING AND
CLINICAL INTERVIEWING
◉ Peau d'orange-
Answer: Lymphatic obstruction causes edema, which thickens the
skin and exaggerates the hair follicles; this creates a pigskin or
orange peel look. Could be an indication of cancer.
◉ Dullness-
Answer: A high-pitched muffled thud sound obtained by percussing
over relatively dense organs such as liver or spleen, distended
bladder, mass of adipose tissue
◉ Tympany-
Answer: A high-pitchedmusical and drum like note obtained by
percussing the surface of a large air-containing space, such as the
abdomen
◉ Resonance-
Answer: A low-pitched, clear, hollow note obtained by percussing
over normal lung tissue
,◉ Hyperresonnance-
Answer: A low-booming note obtained by percussing over the adult
lungs that have increased air such as with a patient who has
emphysema, present with distended abdomen
◉ Which structure is located in the left lower quadrant of the
abdomen?
Answer: Sigmoid colon
◉ Aneurysm-
Answer: defect or sec formed by dilation in artery wall due to
atherosclerosis, trauma, or congenital defect (aortic aneurysm)
◉ Dysphasia-
Answer: Difficulty swallowing
◉ Anorexia-
Answer: Loss of appetite
◉ Ascites
Answer: abnormal accumulation of serous fluid within the
peritoneal cavity, associated with heart failure, cirrhosis, cancer or
portal hypertension
,◉ Bruit-
Answer: blowing, swoishing sound her through a stethoscope when
an artery is partially occluded
◉ Hepatomegaly-
Answer: abnormally enlarged liver
◉ Paralytic ileus-
Answer: complete absence of peristaltic movement that may follow
abdominal surgery or complete bowel obstruction
◉ Peritonitis-
Answer: inflammation of the peritoneum
◉ Nurse suspects a patient has a distended bladder. How should the
nurse assess?
Answer: Percuss and palpate the midline area above the suprapubic
bone.
◉ The nurse is aware that one change that may occur in the
gastrointestinal system of an aging adult is:
Answer: Decreased gastric acid secretion.
, ◉ A patient has hypoactive bowel sounds. The nurse knows that a
potential cause of hypoactive bowel sounds is:
Answer: Peritonitis,
◉ The nurse is watching a new graduate nurse perform auscultation
of a patient's abdomen. Which statement by the new graduate shows
a correct understanding of the reason auscultation precedes
percussion and palpation of the abdomen?
Answer: "Auscultation prevents distortion of bowel sounds that
might occur after percussion and palpation."
◉ Abdominal borborygmi-
Answer: Hyperactive bowel sounds
◉ Percussion notes heard during the abdominal assessment may
include:
Answer: Tympany, hyperresonnance, and dullness.
◉ Causes of Abdominal Distention-
Answer: Obesity, Ascites, Air or Gas, Ovarian cyst, Pregnancy, Tumor
◉ Before reporting silent bowel sounds, the nurse should listen for
at least:
HANDBOOK 2026 HISTORY TAKING AND
CLINICAL INTERVIEWING
◉ Peau d'orange-
Answer: Lymphatic obstruction causes edema, which thickens the
skin and exaggerates the hair follicles; this creates a pigskin or
orange peel look. Could be an indication of cancer.
◉ Dullness-
Answer: A high-pitched muffled thud sound obtained by percussing
over relatively dense organs such as liver or spleen, distended
bladder, mass of adipose tissue
◉ Tympany-
Answer: A high-pitchedmusical and drum like note obtained by
percussing the surface of a large air-containing space, such as the
abdomen
◉ Resonance-
Answer: A low-pitched, clear, hollow note obtained by percussing
over normal lung tissue
,◉ Hyperresonnance-
Answer: A low-booming note obtained by percussing over the adult
lungs that have increased air such as with a patient who has
emphysema, present with distended abdomen
◉ Which structure is located in the left lower quadrant of the
abdomen?
Answer: Sigmoid colon
◉ Aneurysm-
Answer: defect or sec formed by dilation in artery wall due to
atherosclerosis, trauma, or congenital defect (aortic aneurysm)
◉ Dysphasia-
Answer: Difficulty swallowing
◉ Anorexia-
Answer: Loss of appetite
◉ Ascites
Answer: abnormal accumulation of serous fluid within the
peritoneal cavity, associated with heart failure, cirrhosis, cancer or
portal hypertension
,◉ Bruit-
Answer: blowing, swoishing sound her through a stethoscope when
an artery is partially occluded
◉ Hepatomegaly-
Answer: abnormally enlarged liver
◉ Paralytic ileus-
Answer: complete absence of peristaltic movement that may follow
abdominal surgery or complete bowel obstruction
◉ Peritonitis-
Answer: inflammation of the peritoneum
◉ Nurse suspects a patient has a distended bladder. How should the
nurse assess?
Answer: Percuss and palpate the midline area above the suprapubic
bone.
◉ The nurse is aware that one change that may occur in the
gastrointestinal system of an aging adult is:
Answer: Decreased gastric acid secretion.
, ◉ A patient has hypoactive bowel sounds. The nurse knows that a
potential cause of hypoactive bowel sounds is:
Answer: Peritonitis,
◉ The nurse is watching a new graduate nurse perform auscultation
of a patient's abdomen. Which statement by the new graduate shows
a correct understanding of the reason auscultation precedes
percussion and palpation of the abdomen?
Answer: "Auscultation prevents distortion of bowel sounds that
might occur after percussion and palpation."
◉ Abdominal borborygmi-
Answer: Hyperactive bowel sounds
◉ Percussion notes heard during the abdominal assessment may
include:
Answer: Tympany, hyperresonnance, and dullness.
◉ Causes of Abdominal Distention-
Answer: Obesity, Ascites, Air or Gas, Ovarian cyst, Pregnancy, Tumor
◉ Before reporting silent bowel sounds, the nurse should listen for
at least:
