NUR 2092/NUR2092 Exam 3 V2 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When performing an abdominal assessment, what is the correct sequence of techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Answer: B
Rationale: The abdomen is assessed in the order of inspection, auscultation, percussion,
and palpation. This sequence is unique to the abdomen because percussion and palpation
can increase peristalsis, which would result in false bowel sound findings. Following this
order ensures the most accurate representation of the patient’s bowel activity.
2. A nurse hears loud, gurgling bowel sounds while assessing a patient’s abdomen. How
should the nurse document this finding?
A. Hypoactive bowel sounds
B. Normal bowel sounds
C. Bruits
D. Borborygmi
,Answer: D
Rationale: Borborygmi are hyperactive bowel sounds that are loud, gurgling, and indicate
increased motility. They are common in cases of hyperactive peristalsis, such as early
bowel obstruction or diarrhea. Documentation should accurately reflect the intensity and
frequency of these sounds to assist in diagnosis.
3. During an assessment of the abdomen, the nurse notes a positive Blumberg sign. What
does this indicate?
A. Gallbladder inflammation
B. Peritoneal irritation or appendicitis
C. Spleen enlargement
D. Kidney infection
Answer: B
Rationale: The Blumberg sign, also known as rebound tenderness, is assessed by pushing
down slowly and deeply, then withdrawing the hand quickly. Pain felt upon the release of
pressure is a positive sign and strongly suggests peritoneal inflammation. It is commonly
associated with acute appendicitis or generalized peritonitis.
4. The nurse is checking for costovertebral angle (CVA) tenderness. Which organ is being
assessed?
A. The Liver
B. The Kidney
, C. The Spleen
D. The Pancreas
Answer: B
Rationale: CVA tenderness is checked by placing one hand over the 12th rib at the
costovertebral angle on the back and thumping that hand with the ulnar edge of the other
fist. A patient feeling sharp pain during this maneuver typically indicates inflammation of
the kidney, such as pyelonephritis. This assessment is a standard part of the posterior
physical examination for renal health.
5. What is the normal expected sound when percussing over most of the abdominal area?
A. Tympany
B. Dullness
C. Resonance
D. Hyperresonance
Answer: A
Rationale: Tympany is the predominant sound heard over the abdomen during percussion
because of the presence of air in the intestines. Dullness may be heard over solid organs
like the liver or spleen, or over a distended bladder. Resonance is typically found over
healthy lung tissue, not the abdomen.
Assessment Q&A with Rationale |
Rasmussen University
1. When performing an abdominal assessment, what is the correct sequence of techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Answer: B
Rationale: The abdomen is assessed in the order of inspection, auscultation, percussion,
and palpation. This sequence is unique to the abdomen because percussion and palpation
can increase peristalsis, which would result in false bowel sound findings. Following this
order ensures the most accurate representation of the patient’s bowel activity.
2. A nurse hears loud, gurgling bowel sounds while assessing a patient’s abdomen. How
should the nurse document this finding?
A. Hypoactive bowel sounds
B. Normal bowel sounds
C. Bruits
D. Borborygmi
,Answer: D
Rationale: Borborygmi are hyperactive bowel sounds that are loud, gurgling, and indicate
increased motility. They are common in cases of hyperactive peristalsis, such as early
bowel obstruction or diarrhea. Documentation should accurately reflect the intensity and
frequency of these sounds to assist in diagnosis.
3. During an assessment of the abdomen, the nurse notes a positive Blumberg sign. What
does this indicate?
A. Gallbladder inflammation
B. Peritoneal irritation or appendicitis
C. Spleen enlargement
D. Kidney infection
Answer: B
Rationale: The Blumberg sign, also known as rebound tenderness, is assessed by pushing
down slowly and deeply, then withdrawing the hand quickly. Pain felt upon the release of
pressure is a positive sign and strongly suggests peritoneal inflammation. It is commonly
associated with acute appendicitis or generalized peritonitis.
4. The nurse is checking for costovertebral angle (CVA) tenderness. Which organ is being
assessed?
A. The Liver
B. The Kidney
, C. The Spleen
D. The Pancreas
Answer: B
Rationale: CVA tenderness is checked by placing one hand over the 12th rib at the
costovertebral angle on the back and thumping that hand with the ulnar edge of the other
fist. A patient feeling sharp pain during this maneuver typically indicates inflammation of
the kidney, such as pyelonephritis. This assessment is a standard part of the posterior
physical examination for renal health.
5. What is the normal expected sound when percussing over most of the abdominal area?
A. Tympany
B. Dullness
C. Resonance
D. Hyperresonance
Answer: A
Rationale: Tympany is the predominant sound heard over the abdomen during percussion
because of the presence of air in the intestines. Dullness may be heard over solid organs
like the liver or spleen, or over a distended bladder. Resonance is typically found over
healthy lung tissue, not the abdomen.
