Quiz 6: NURS190 / NURS 190 (Latest 2026 / 2027 Update) Physical Assessment | Questions & Answers | Grade A | 100% Correct – WCU

Quiz 6: NURS190 / NURS 190 (Latest 2026 / 2027 Update) Physical Assessment | Questions & Answers | Grade A | 100% Correct – WCU Q: What are the three systems in the abdomen? Answer Reproductive, digestive, urinary Q: Where is your McBurney's point Answer Middle third of the right lower quadrant Q: What patients are more prone to hepatitis C? Answer Patients with tattoos Q: Which patients are more prone to hepatitis A? Answer Children Q: Which patients are more prone to Hep E? Answer Travelers Q: What is the contours of a patient with ascites? Answer Protuberant or convex Q: What patients present with protuberant tummies? Answer Toddler and pregnant women on their third trimester Q: Concave abdomen is also known as? Answer Scaphoid Q: Concave abdomen is common in which patients? Answer Very thin patients Q: Flat abdomen is common in which patients? Answer Thin patients Q: Why do you start you auscultation of the abdomen at the right lower quadrant? Answer The bowel sounds are loudest and found there Q: How many bowel sounds should be heard within a minute to be considered normoactive, hypoactive and hyperactive? Answer Normoactive: 5-30x/minute Hypoactive: 5/minute Hyperactive: 30/minute Q: When listening to the abdomen what is the last you have to pay attention to? Answer Strong pulsation especially when accompanied with lower back pain Q: If you are assessing a patient and you noted a large hematoma on the costovertibal angle what organ are you worried about? Answer The kidneys Q: What is the difference in positioning of the kidneys and why? Answer The right kidney is lower due to the liver Q: When percussing a distended bladder what technique do you use? Answer Indirect percussion Q: When percussing for CVAT what technique do you use? Answer Indirect blunt percussion Q: When assessing a patient with a distended bladder what position should the patient be in? Answer Supine with small pillow in the head Q: What is the procedure that you use to assess for cholecystitis? Answer Murphy's sign Q: What do you call rebound tenderness in the abdomen? Answer Bloomberg sign Q: What is the sign called when you compress the LLQ and the pain is felt on the right ? Answer Mcburneys sign Q: What are you testing when having your patient lay supine and raise their right leg checking for abdominal pain? Answer For appendicitis When assessing the abdomen what organs are in the RUQ? Answer Liver and gallbladder When assessing the abdomen what organs are in the LUQ? Answer Stomach spleen What is it called when a patient has a difficulty urinating? Answer Dysuria Blood in the urine is called Answer hematuria frequent urination Answer polyuria urinary output less than 100 in 24 hours Anuria Urinary output is less than 400 in 24 hours Oliguria What is the sequence of abdominal assessment? Inspect, Auscultate, Percuss, Palpate What are the hepatitis that the route of contamination is oral fecal? A and E What are the hepatitis that the route of contamination is blood? B C D What are the landmarks for abdominal assessment? Xiphoid process, umbilicus, costal margin, iliac Pubic bone What area do you percuss when looking for CVAT? Costovertebral angle What is the condition when the patient intakes a lot of fluid but output is minimal? Urinary retention How many cm for light palpating if the abdomen? 1/2-1cm using one hand and finger pads Concave stomach is usually present in patients with what disease? Anorexia nervosa When your patient is complaining of abdominal pain what is the first assessment that you do? Inspect What is the technique of abdominal assessment that you do before percussion? Auscultation Who's going to get 100 on this Quiz? You are! What technique of abdominal assessment before palpating? Percussion What do you call a tumor found in toddlers that you have to stop palpating once you find it? Whilms tumor Is a protuberant abdomen common in infants and toddlers? Yes How long is the the small intestine? 18-21 feet How long is the colon? 5 feet How long is the esophagus? 10 inches What can cause an enlargement of the spleen? Acute mono Is there any intervention for an umbilical hernia for a pediatric patient under 5 years old with no symptoms? No only if there are symptoms and after age 5 What do you call the cigar shaped mass in the left lower quadrant? Constipation or stool Is gurgling sound in your stomach normal? Yes if you haven't been eating for a period of time If the abdomen is filled with air what sound will you hear? Hyper resonance What sound do you hear when percussing the liver or spleen? Dullness What is the normal sound heard from percussing the abdomen? Tympani What is the average size of the aorta? 3cm What is the cluster of capillaries in the kidneys? Glomerili filtering 1 L of fluid per min Frequent urination at night? nocturia What are the enzymes that are released by the kidneys to regulate blood pressure? Rennin Central nervous system (CNS) -Consists of the brain and the spinal cord -Responsible for control of cognitive function &: Both voluntary & involuntary actions Peripheral nervous system (PNS) includes: -Cranial nerves & spinal nerves •They work together to receive an impulse, interpret it, & initiate a response, enabling the individual to maintain high level of adaptation & homeostasis The factors that influence neurological health are: -Diet -Alcohol intake -Smoking & other health practices The cerebral cortex enables the individual to... -perceive -remember -communicate -initiate voluntary movements Frontal lobe -Controls voluntary skeletal movement -speech -emotions -intellectual activities Parietal lobe Responsible for conscious awareness of sensation & somatosensory stimuli: Temp., pain, shapes, two-point discrimination and stereognosis testing). Occipital lobe -Visual cortex- Receives stimuli from the retina & interprets the visual stimuli in relation to past experiences Temporal lobe Interprets auditory stimuli Cerebral Cortex -Composed of gray matter -Responsible for all conscious behavior -Enables the individual to perceive, remember, communicate & initiate voluntary movement Cerebellum Coordinates stimuli from the cerebrum and behind the brain stem Brain stem consists of midbrain, pons, medulla oblongata brain stem function 1. control heartbeat hing preasure Reflexes are fast, predictable, unlearned, innate, and involuntary reactions to stimuli The vagus nerve is the only CN to.... serve a muscle & body region below the neck Cranial nerves produce... Sensory, motor & mixed nerves Cranial Nerve I Olfactory (sensory)- smell Cranial Nerve II Optic (sensory)- vision Cranial Nerve III Oculomotor (motor)- pupillary reflex, muscle movement Cranial Nerve IV Trochlear (motor)- eye muscle movement Cranial Nerve V Trigeminal (mixed) - chewing face & mouth touch & pain Cranial Nerve VI Abducens (mixed) - eye muscle movement Cranial Nerve VII Facial (mixed) - controls most facial expressions & secretion of tears & saliva & taste Cranial Nerve VIII Vestibulocochlear (sensory)- hearing and balance Cranial Nerve IX Glossopharyngeal (mixed) - Gag reflex, swallowing, taste in posterior 1/3 of tongue Cranial Nerve X Vagus (mixed)- innervates muscles of throat and mouth for swallowing and talking Cranial Nerve XI Accessory (motor)- movement of the trapezius and sternocleidomastoid Cranial Nerve XII Hypoglossal (motor)- Movement of the tongue; strength of the tongue Dermatone Area of skin innervated by the cutaneous branch of one spinal nerve Ex) shingles All spinal nerves except C1 serve a... cutaneous region Assessment Techniques for Neurological System: •Inspection •Palpation •Auscultation of the carotid arteries •Sensory and motor function •Reflexes Glasgow Coma Scale eyes, verbal, motor 15 pts: alert, responsive & oriented 3 pts: non-responsive & coma Glasgow Coma Scale has limitations with... specific pts, (ET/trachea) cannot verbally communicate. Supination and Pronation Test assesses upper cerebellum test Heel to Shin test assesses lower cerebellum test Anesthesia loss of sensation Hyperesthesia increased sensation Hypoesthesia decreased sensation Analgesia inability to feel pain Hypalgesia diminished sensation to pain graphesthesia with eyes closed, client can identify a number drawn on his palm with the blunt end of a pencil Inability to perceive a number on the skin may indicate cortical disease Testing the biceps reflex Look for contraction of the biceps muscle & slight flexion of the forearm. Absent/diminished/hypoactive reflexes= neuromuscular disease, spinal cord injury or lower motor neuron disease. Testing the triceps reflex C5 and C6 Sharply percuss/strike the tendon just above the olecranon process with the pointed end of the reflex hammer Observe contraction of the triceps muscle with extension of the lower arm. Testing the brachioradialis reflex C5 and C6 Briskly strike the tendon toward the radius about 2 to 3 inches above the wrist Observe flexion of the lower arm & supination of the hand. Testing patellar reflex L2, L3, L4 Palpate the patella to locate the patellar tendon inferior to the patella Briskly strike the tendon with the flat end of the reflex hammer. May use a relaxation technique. Babinski response Fanning of the toes with the toe pointing toward the dorsum of the foot. This called dorsiflexion of the toe is considered an abnormal response in the adult. It may indicate upper motor neuron disease. It's normal in the child until about 2 years of age. A Babinski response in an adult is an abnormal finding Scissors gait -Spastic lower limbs and movement in a stiff jerky manner -commonly seen in multiple sclerosis Steppage gait "foot drop walk" -flopping of the foot -commonly seen in alcoholic neuritis and progressive muscular atrophy Festination gait "Parkinson's Walk" -stooped posture -short steps -turns stiffly -associated with basal ganglia disease Problems associated with dysfunction of cranial nerve I Unilateral or bilateral anosmia Problems associated with dysfunction of cranial nerve II Optic atrophy, papilledema, amblyopia, field defects Problems associated with dysfunction of cranial nerve III Diplopia, ptosis, dilated pupil, inability to focus on close objects ptosis drooping Problems associated with dysfunction of cranial nerve IV convergent strabismus Problems associated with dysfunction of cranial nerve V loss of facial sensation, decreased ability to chew, loss of corneal reflex, decreased blinking Problems associated with dysfunction of cranial nerve VI diplopia, strabismus Problems associated with dysfunction of cranial nerve VII Bell's palsy, decreased ability to distinguish tastes Problems associated with dysfunction of cranial nerve VIII tinnitus, vertigo, deafness Problems associated with dysfunction of cranial nerve IX loss of gag reflex, loss of taste, difficulty swallowing Problems associated with dysfunction of cranial nerve X loss of voice, impaired voice, difficulty swallowing Problems associated with dysfunction of cranial nerve XI difficulty with shrugging shoulders, inability to turn head left and right Problems associated with dysfunction of cranial nerve XII Difficulty with speech and swallowing, inability to protrude tongue Meningitis Virus or bacteria that infects the coverings (meninges) of the brain or spinal cord nuchal rigidity stiffness in cervical neck area Myelitis -Inflammation of the spinal cord -Commonly due to poliomyelitis and herpes zoster infection Brain abscess -Accumulation of pus in the brain cells -Usually secondary to systemic infection Lyme disease -Infection caused by spirochete transmitted by a bite from an infected tick that lives on a deer -If untreated, can cause Bell palsy, visual disturbances, and nerve damage Alzheimer disease Progressive degenerative disease of the brain that leads to dementia Amyotrophic lateral disease -Chronic degenerative disease involving cerebral cortex and motor neurons in the spinal cord -Progressive wasting of muscles leading to death Huntington disease -Inherited disorder characterized be uncontrollable jerking movements (chorea) -Progresses to mental deterioration, death Multiple sclerosis -Deterioration of protective sheaths of myelin of the nerve tracts in the brain and spinal cord Myasthenia gravis -Chronic neuromuscular disorder involving increasing weakness of voluntary muscles with activity, and abatement with rest -Believed to be an autoimmune disorder Parkinson disease -Degeneration of the basal nuclei of the brain -Responsible for initiating and stopping voluntary movement -Precise etiology unknown The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse would suspect cranial nerve involvement in which of the following? a. Trochlear (CN LV) b. Trigeminal (CN V) c. Olfactory (CN l) d. Oculomotor (CN lll) C The nurse is admitting a client with suspected meningitis. During the assessment, the nurse asks the client to flex the chin down toward the chest. The client verbalizes pain and stiffness during this action. The nurse documents this as which of the following? a. Muscle spasms b. Neck strain c. Nuchal rigidity d. Brudzinski's sign C The student nurse is reviewing the cranial nerves (CN). The student recognize that some of the nerves are exclusively sensory nerves. Which of the following CN belong to this group? (Select all that apply). a. Trochlear nerve (CN lV) b. Trigeminal nerve (CN V) c. Vestibulocochlear nerve (CN Vlll) d. Olfactory nerve (CN l) e. Optic nerve (CN ll) CDE what is the largest cavity of the body? abdomen what systems does the abdomen contain? digestive system urinary system reproductive system what is the alimentary canal? a hollow tube from the mouth to the anus what is the size of the esophagus? 10 inches long what is the size of the stomach? dependent on how much food has been eaten what is the size of the small intestine? 18-21 feet long what is the size of the large intestine? 5-5.5 feet long what is the largest gland of the body? liver what does the liver produce? bile antibody substance for coagulation protien, fat, carb metabolism detoxify harmful substances stores vitamins what is the function of the gallbladder? stores bile releases bile for fat emulsification what is the function of the endocrine gland pancreas? secretes insulin for carb and sugar metabolism what is the function of the exocrine gland pancreas? secretes pancreatic juice to assist with digestion of protein, fat and carb what is the pancreas? exocrine and endocrine gland what is the largest lymphoid organ? spleen what is the function of the spleen? graveyard for RBC site for lymphocytic proliferation filters blood destroys worn out RBC (returned to the liver) what is the urinary system composed of? kidneys ureter bladder urethra what are the glomeruli? clusters of capillaries of the kidneys that filter 1L of fluid per minute what are the landmarks of the urinary system? costovertebral angle rectus abdominus symphysis pubis what are the abdominal landmarks? xyphoid process umbilicus costal margin illiac crest pubic bone what is a major concern as an individual advances with age? urinary elimination what urinary concern is common in elderly women? urinary incontinence frequent void/urgency what urinary concern is common in elderly men? urinary retention what is common in age 75 and older? loss of nephrons leading to less glomerular filtration = susceptability to drug toxicity where is benign prostatic hypertrophy (BPH) most common? common in 95% of men age 85 and older resulting in urinary retention/trickling of voiding what is urolithiasis (renal calculi)? renal stones blocking the urinary tract what is nursing intervention for renal calculi? strain all urine save renal stones report to MD what is a risk factor for urolithiasis? family history what can you do for a patient with urolithiasis? *ensure NO fluid restriction encourage fluid intake of 3L per day what is mapping of the abdomen? dividing the abdomen into 4 quadrants or 9 regions for the purpose of a PA which organs are located in the RUQ? liver gallbladder which organs are located in the LUQ? stomach spleen which organs are located in the RLQ? appendix what is LLQ pain associated with? diverticular diseases what is heard on percussion of mass, organs, pregnant women, liver or tumors? dullness what is the strict sequence of abdominal assessment? inspection auscultation percussion palpation which abnormal finding should be reported on inspection of the abdomen that requires immediate intervention? strong abdominal pulsation (indication of abdominal aortic aneurysm (AAA)) where should you begin abdominal auscultation for bowel sounds? RLQ what is the best position for assessing the abdomen for bladder distention? supine with small pillow under the head which assessment is used for assessing bladder distention? indirect percussion what is abdominal contour of slightly skinny individual? flat what is abdominal contour of very skinny individual? scaphoid what is abdominal contour of a fat individual? rounded to protuberant what is the abdominal contour of an infant? rounded to protuberant what is abdominal contour or an individual with ascites (fluid buildup)? protuberant what is the abdominal contour of 3rd trimester pregnancy? protuberant what should a nurse expect with large hematoma located at the CVA (costovertebral angle)? injuries to the kidneys what percussion is used for large hematoma at the CVA? blunt percussion what percussion is used for costovertebral angle tenderness (CVAT)? blunt percussion what does pain with blunt percussion on CVA indicate? kidney diseases when are the kidneys palpable? presence of neoplasms cancer polycystic diseases why is bladder cancer more common in men? it is linked to smoking what does acute renal failure include before becoming chronic? stage 1: oliguria (small amounts of urine) stage 2: diuresis (excessive amounts of urine) stage 3: recovery what is uremia? urine product buildup in the blood hallmark for chronic renal failure what is uremic frost? crystalized urea on the skin what is azotemia? high level of nitrogen compound in the blood due to inefficient functioning of the kidneys what is urinary incontinence? inability to retain urine what are the 5 types of incontinence? functional reflex incontinence stress incontinence urge incontinence total incontinence what is urinary retention? inability to excrete urine what indicates retaining of fluids? when the patient output is less than the intake of fluids what indicates excretion of excess fluids? when the patient output exceeds the intake of fluids what is dysuria? painful urination what is nocturia? excessive urination at night what is anuria? less than 100 cc of urine output in 24 hours what is oliguria? less than 400 cc of urine output in 24 hours what is glycosuria? sugars in the urine what is hematuria? blood in the urine what is the normal range of urine output in 24 hours? 800-2000 cc equivalent to intake of patient (800-2000 cc) what is the major role of the kidney with an excessive drop in blood pressure? releases/secrete renin to regulate BP what is hepatitis? inflammation of the liver caused by virus, bacteria, chemicals, drugs where is hepatitis A most common? children because they do not wash hands before eating where is hepatitis E most common? those who travel to india, africa, asia, and central america what route is hepatitis A and E contracted? fecal and oral where is hepatitis C most common? individuals with tattoos (blood, parenterally) where is hepatitis B and D most common? sexually transmitted blood and blood products parenterally what is chrons disease? chronic inflammation of the lower intestine s/s: abdominal pain diarrhea remission (no surgical treatment) what is colitis? inflammation of the colon s/s: abdominal pain diarrhea bloody stool (long term medical interventions) what is splenomegaly? enlargement of the spleen due to infection what is mononucleosis (kissing disease) caused by? ebstein barr virus (herpesvirus 4) what can be fatal in children? dehydration what are indications of dehydration in children? low LOC weight loss low urine output what is an indication of aneurysm? widened aorta 3cm what is normal size of the aorta? 3cm what indicates acute appendicitis? pain in mcburney's point where is mcburney's point? RLQ from inguinal to umbillicus, middle 3rd of imaginary line what is a positive lumbergh's sign? emergency and alert stabbing pain as compressed abdomen turns to non compressed state due to peritoneum irritation what is a positive murphy sign? sharp pain of RUQ when palpating the lower border of the liver what can positive murphy sign indicate? positive to cholecystitis what is positive rovsing's sign? pain at RLQ when palpating the LLQ what does positive rovsing's sign indicate? acute appendicitis peritoneal irritation what is positive psoas sign? pain at the RLQ when patient in supine with right leg raised up with resistance what does a positive psaos sign indicate? positive appendicitis what is positive cullen sign? ecchymosis or bruising at periumbilical area what does positive cullen sign indicate? bleeding in the abdomen ex: ruptured ectopic pregnancy which lab test is ordered for acute kidney injury? BUN what indicates an elderly patient complaining of sudden onset of urinary incontinence? cystitis (UTI) what indicates palpation of a mass on abdomen of pediatrics? malignancy of kidney wilms tumor STOP assessment what is indicated with cigar shaped.. palpated at the LLQ? constipation when is umbilical hernia in children resolved? before age 5 (surgery indicated if it persists) how often are normal bowel sounds heard? 5-30 times per minute in each quadrant irregular high pitched gurgling what is borborygmi? normal bowel sound heard when not eating for 5-7 hours indicates abdominal bleeding or inflammatory bowel diseases