NURS 190 / NURS190 Final Exam: (Latest Update 2025 / 2026) Physical Assessment | Review Questions and 100% Correct Answers | Grade A | - West Coast

NURS 190 / NURS190 Final Exam: (Latest Update 2025 / 2026) Physical Assessment | Review Questions and 100% Correct Answers | Grade A | - West Coast The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what? - Correct Answer Bruit bruit - Correct Answer abnormal blowing or swishing sound heard during auscultation of an artery or organ Borborygmi - Correct Answer loud, gurgling bowel sounds signaling increased motility or hyperperistalsis; occurs with early bowel obstruction, gastroenteritis, diarrhea Venous Hum - Correct Answer A continuous murmur heard on auscultation over the major veins at the base of the neck or around the umbilicus; not normally heard; heard best with the diaphragm of the stethoscope A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action? - Correct Answer Ask the client when the pain began. If a client has an acute abdominal problem, the history and physical examination will be focused on that problem, so that much of the history taking will be eliminated. Severe dehydration from nausea and vomiting, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Pain is the chief complaint and should be assessed before a diet recall, obtaining a health history, and identifying risk factors. The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be? - Correct Answer Suprapubic A student nurse is performing a focused abdominal assessment of a hospitalized client. The nursing instructor determines proper assessment technique when the nursing student performs the assessment in what order? - Correct Answer inspection auscultation percussion and palpation The sigmoid colon is located in this area of the abdomen: the - Correct Answer left lower quadrant. The left lower quadrant (LLQ) contains the left kidney (lower pole), left ovary and tube, left ureter, left spermatic cord, and descending and sigmoid colon. Left Lower Quadrant (LLQ) - Correct Answer refers to the area encompassing portions of the small and large intestines, the left ureter, and the left ovary and uterine tube in women or the left spermatic duct in men Left Upper Quadrant (LUQ) - Correct Answer Left lobe of liver, stomach, pancreas, left kidney, spleen, portions of large intestine Right Lower Quadrant (RLQ) - Correct Answer refers to the area encompassing portions of the small and large intestines, the appendix, the right ureter, and the right ovary and uterine tube in women or the right spermatic duct in men Right Upper Quadrant (RUQ) - Correct Answer refers to the area encompassing the right lobe of the liver, the gallbladder, medial portion of the pancreas, and portions of the small and large intestines An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What medical diagnosis is associated with the assessment finding? - Correct Answer Appendicitis Rovsing's sign - Correct Answer Pain in RLQ with palpation of LLQ indicative of appendicitis A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause? - Correct Answer Crohn's disease Hyperextending the client's right leg is an assessment for the - Correct Answer psoas sign. If pain occurs in the right upper quadrant, this is associated with irritation of the iliopsoas muscle due to appendicitis. Where is the linea alba located? - Correct Answer Midline of the abdomen extending from xiphoid process to symphis pubis Which of the following people need to be vaccinated for hepatitis A and B? - Correct Answer Food-service workers Hepatitis A and B immunizations are recommended for all infants; people whose work may expose them to blood, body fluids, or unsanitary conditions (i.e., health care, food services, sex workers); and those traveling to parts of the world where these illnesses are prevalent A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition? - Correct Answer viral hepatitis Travel to or consuming food meals in an area of poor sanitation can pose a risk for contracting viral hepatitis. This information paired with the client's report of having gray colored stools increases the likelihood of obstructive jaundice related viral hepatitis. A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ? - Correct Answer Spleen The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible - Correct Answer paralytic ileus. The nurse is assessing a surgical wound. What symptoms would lead the nurse to believe the wound is infected? - Correct Answer Swelling Redness Warmth The nurse would assess for positive Blumberg sign how? - Correct Answer Applying and releasing pressure to the abdomen Blumberg's sign - Correct Answer The experience of sharp, stabbing pain as the compressed area returns to a noncompressed state During deep palpation of the abdomen, a client experiences right lower quadrant rebound tenderness. The nurse should conduct which additional assessments? - Correct Answer Palpate for the Rovsing's sign. Assess for a Psoas sign. Assess for the Obturator sign. Psoas sign - Correct Answer RLQ pain with extension of right thigh indicative of appendicitis Obturator sign - Correct Answer RLQ pain on internal rotation of right thigh indicative of appendicitis A nurse receives an order to measure the abdominal girth daily on a client admitted with ascites. How should the nurse best implement this order? - Correct Answer Measure at the same time each day, ideally in the morning after voiding The umbilicus should be used as the starting point for measuring abdominal girth, especially when ascites is present. Measure the girth at the same time each day, ideally after the client voids in the morning. The ideal position is for the client to stand. If the client cannot stand, the supine position is acceptable. The head of bed should be flat unless the client has difficulty breathing. Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely? - Correct Answer Appendicitis This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration. The abdominal contents are enclosed externally by the abdominal wall musculature—three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external - Correct Answer abdominal oblique. A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment? - Correct Answer place a small pillow under the client's knees While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound? - Correct Answer Borborygmus Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling." A client presents to the emergency department with reports of new onset of abdominal pain for the past 3 days. The client states there is also a pulling feeling on the right side. Upon examination, the nurse notices a 5-cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process? - Correct Answer Internal adhesions from previous surgery The key to this question is the presence of the scar. The scar in the right lower quadrant should alert the nurse to the possibility of internal adhesions, which account for the pulling feeling the client reports. Which action by the nurse will facilitate relaxation of the abdominal muscles during examination of the abdomen? - Correct Answer Flex the client's legs by placing a pillow under the knees The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the - Correct Answer costovertebral angle. The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible - Correct Answer internal bleeding. Purple discoloration at the flanks (Grey-Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis. How should the nurse perform blunt percussion over the liver? - Correct Answer Place left hand on right lower rib cage, strike it with ulnar side of right fist To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's - Correct Answer right lower quadrant. As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? - Correct Answer Right upper quadrant Which of the following is consistent with obturator sign? - Correct Answer Right hypogastric pain with the right hip and knee flexed, and the hip internally rotated Obturator sign is seen in appendicitis. It is pain with the stretching of the internal obturator muscle because of inflammation. The nurse is assessing a client's abdomen. For which reason should the nurse perform deep palpation? - Correct Answer identify abdominal organs On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity? - Correct Answer Fluid accumulation Pale and taut skin indicates significant abdominal swelling caused by accumulation of fluid in the abdominal cavity, or ascites. Bleeding within the abdominal wall would manifest as purple discoloration at the flanks. Inflammation of the peritoneum and obstruction of the intestine does not contribute to pale and taut abdominal skin. The peritoneum is a serous membrane that contains which of the following? - Correct Answer A parietal layer A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse? - Correct Answer Listen for a total of 5 minutes Bowel sounds normally occur every 5 to 15 seconds. In a client with nausea and vomiting, bowel sounds may be hypoactive. The nurse should listen for a total of 5 minutes to confirm the absence of bowel sounds. When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant? - Correct Answer Right kidney, ascending colon, and liver A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regard to this finding? - Correct Answer "Have you been pregnant?" Striae are silvery white marks that are common on the abdomen from stretching of the skin during pregnancy or weight gain. They do not cause pain or any other color changes to the skin. The nurse identifies the client has a positive Obturator sign. The nurse identifies this is due to what? - Correct Answer Appendicitis Your client describes her stool as soft, light yellow to gray, mushy, greasy, foul-smelling, and usually floats in the toilet. What would you suspect is wrong with your client? - Correct Answer Malabsorption syndrome A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause? - Correct Answer Gastric ulcer When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? - Correct Answer right upper A nurse cares for a client with a duodenal ulcer. The nurse knows that which characteristic of pain is generally associated with the client's condition? - Correct Answer May awaken the client at night A client with duodenal ulcers would have severe pain that awakens him at night. The pain may not increase by the intake of food but may be relieved by it. The pain is unrelated to drinking water. The nature of the pain may vary and may not necessarily be throbbing. What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen? - Correct Answer Hypogastric The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right inguinal, hypogastric, and left inguinal. When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what? - Correct Answer Abdominal aortic aneurysm Which change in auscultation of bowel sounds should the nurse recognize as most diagnostic of an intestinal obstruction? - Correct Answer An increase in the pitch An increase in the pitch of bowels sounds is most diagnostic of obstruction because it signifies intestinal distention. A soft click or gurgle every 5-15 seconds is normal. An increase in the frequency of bowel sounds can be normal and is characteristic of stomach growling. Bowel sounds should be auscultated for 5 minutes to confirm their absence. The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant with right flank pain. Which assessment should the nurse conduct next? - Correct Answer Palpate the right lower quadrant for rebound tenderness. Localized tenderness anywhere in the right lower quadrant, even in the right flank, suggests appendicitis. The nurse should follow this finding with an assessment of rebound tenderness. This will assist the nurse in determining if the client is guarding and develops muscle rigidity-two additional features of appendicitis. Murphy's sign - Correct Answer pain with palpation of the RUQ during inspiration, indicative of cholecystitis Cholycstitis - Correct Answer inflammation of the gallbladder Odynophagia - Correct Answer pain with swallowing dyspepsia - Correct Answer indigestion dysphagia - Correct Answer difficulty swallowing On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity? - Correct Answer Fluid accumulation A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test? - Correct Answer Murphy's The gallbladder is located in the right upper quadrant of the abdomen. When it is inflamed (cholecystitis), performing the Murphy's sign will cause the client to hold the breath (inspiratory arrest). A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement? - Correct Answer Measure abdominal girth Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely? - Correct Answer Irritable bowel syndrome Although colon cancer should be a consideration, these symptoms are intermittent and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely, especially given that she is a young woman. This very common condition can be triggered by certain foods and stress. During the abdominal examination, a nurse presses her fingers at the client's right costal margin and tells the client to inhale. At this point, the client holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This test is positive for which sign - Correct Answer Murphy's The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain? - Correct Answer Dyspepsia For more chronic symptoms, dyspepsia is defined as chronic or recurrent discomfort or pain centered in the upper abdomen. Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is - Correct Answer usually difficult to localize During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document this finding? - Correct Answer associated manifestations When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding? - Correct Answer Bowel sounds normal. Normal bowel sounds consist of clicks and gurgles that occur at an estimated frequency of 5 to 34 per minute. The nurse should document that the bowel sounds are normal. The nurse is assessing the abdomen of a client. While percussing the abdomen, what normal sound does the nurse expect to hear? - Correct Answer Tympany Generalized tympany predominates over the abdomen because of air in the stomach and intestines. During the abdominal examination, a nurse performs deep palpation in the left lower quadrant. At this point, the client reports pain. This test is positive for which sign? - Correct Answer Rovsing's Rovsing's sign involves pain caused by deep palpation in the left lower quadrant. The obturator sign involves pain in the right lower quadrant as a result of the nurse flexing the client's hip and rotating the leg externally and internally while supporting the client's right knee and ankle. Psoas sign involves pain in the right lower quadrant on hyperextension of the client's right leg and indicates appendicitis. Murphy's sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client's right costal margin and telling the client to inhale. An older client presents with symptoms of pain on urinating. The nurse recognizes that older adults are at increased risk for urinary tract infections for which of the following reasons? - Correct Answer Decreased activity of protective bacteria in the urinary tract A nurse observes tenderness over the costovertebral angle on the right side. The nurse recognizes this as an abnormal finding for which organ? - Correct Answer Kidney The nurse has elicited a positive Murphy sign. What does the nurse recognize this indicates? - Correct Answer Inflammation of the gallbladder Pain with breathing while assessing Murphy sign is an indication of inflammation of the gallbladder. Peritonitis is assessed for rebound tenderness, indicated by Blumberg sign (a sharp, stabbing pain as the examiner releases pressure from the abdomen). Kidney pain is assessed by performing blunt percussion at the costovertebral angles (CVA). Appendicitis is assessed with the iliopsoas muscle test. The client has epigastric pain that is poorly localized and radiates to the back. What would be an important diagnosis to assess for? - Correct Answer Acute pancreatitis A nurse performs light palpation of the abdomen and feels a prominent, nontender, pulsating mass above the umbilicus that measures approximately 6 cm. What is an appropriate action by the nurse? - Correct Answer Stop the palpation and notify the health care provider When inspecting the abdomen, which of the following client positions facilitates correct examination technique? - Correct Answer Supine with arms at sides or folded across chest A nurse inspects a client's abdomen and notices that a bulge is present in the right lower quadrant. How should the nurse further assess this finding using inspection? - Correct Answer Ask the client to raise the head off the bed Asking the client to raise the head off the bed will help the nurse to determine the location of the mass. A mass within the abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is obscured. Palpation and percussion should come after inspection is completed