GNRS 578 HEALTH ASSESSMENT EXAM 2 PREPARATION FOR
2025/2026 COMPLETE 130 QUESTIONS AND CORRECT
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A nurse is assessing a client with ascites. Which of the following findings should
the nurse expect to observe?
a. A rigid and immobile abdomen
b. Hypoactive bowel sounds
c. Hyperactive bowel sounds
d. Tympany on percussion
a. A rigid and immobile abdomen
Rationale: Ascites is the accumulation of fluid in the abdominal cavity, causing
abdominal distension. When assessing a client with ascites, the nurse should
expect to observe a distended abdomen with fluid wave and shifting dullness.
Additionally, the abdomen may be tense, firm, or rigid due to the increased
intra-abdominal pressure caused by the fluid accumulation. Hypoactive bowel
sounds may be present in clients with ascites due to the pressure on the
intestines, but hyperactive bowel sounds are not typically associated with
ascites. Tympany on percussion may be present in areas of the abdomen not
affected by the fluid accumulation.
A nurse is performing a fluid wave test on a client with suspected ascites. Which
of the following findings would indicate a positive fluid wave test?
a. A palpable lump in the abdomen
b. Absence of dullness on percussion
c. A wave of fluid felt on the opposite side of the abdomen
d. Hyperactive bowel sounds on auscultation
Answer: c. A wave of fluid felt on the opposite side of the abdomen
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Rationale: A positive fluid wave test is indicated when a wave of fluid is felt on
the opposite side of the abdomen when the nurse performs percussion on one
side. A palpable lump in the abdomen may indicate a mass, but it is not
indicative of a positive fluid wave test. Absence of dullness on percussion would
indicate a negative fluid wave test. Hyperactive bowel sounds on auscultation
may be present in clients with ascites due to pressure on the intestines, but they
are not indicative of a positive fluid wave test.
A nurse is assessing a client with suspected ascites. Which of the following
conditions is most commonly associated with the development of ascites?
a. Cirrhosis
b. Diabetes mellitus
c. Hypertension
d. Pneumonia
Answer: a. Cirrhosis
Rationale: Cirrhosis is the most common condition associated with the
development of ascites, accounting for approximately 75% of cases. Other
conditions that may lead to ascites include congestive heart failure, nephrotic
syndrome, and certain cancers. Diabetes mellitus, hypertension, and pneumonia
are not typically associated with the development of ascites.
A nurse is caring for a client with ascites. Which of the following interventions
should the nurse implement to manage the client's fluid status?
a. Encourage the client to drink less fluids
b. Administer diuretics as prescribed
c. Restrict the client's sodium intake
d. Limit the client's protein intake
b. Administer diuretics as prescribed
Rationale: Diuretics are the primary pharmacological intervention used to
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manage ascites by promoting the excretion of excess fluid. Encouraging the
client to drink less fluids may worsen dehydration and electrolyte imbalances.
Restricting the client's sodium intake may help reduce fluid retention, but it is
not the primary intervention. Limiting the client's protein intake may lead to
malnutrition and should be avoided.
A nurse is assessing a client's spleen. Which of the following techniques should
the nurse use to assess the spleen?
a. Auscultation
b. Inspection
c. Percussion
d. Palpation
Answer: d. Palpation
Rationale: The spleen is located in the left upper quadrant of the abdomen, and
palpation is the preferred technique for assessing the size and tenderness of the
spleen. Auscultation is used to assess bowel sounds, inspection is used to assess
the skin and contour of the abdomen, and percussion is used to assess for fluid
in the abdomen.
A nurse is performing a spleen assessment on a client. Which of the following
findings would indicate an enlarged spleen?
a. A spleen that is not palpable
b. A spleen that is tender to palpation
c. A spleen that is 1 cm below the costal margin
d. A spleen that is 3 cm below the costal margin
Answer: d. A spleen that is 3 cm below the costal margin
Rationale: An enlarged spleen, also known as splenomegaly, is typically palpable
and can be felt below the costal margin. A spleen that is not palpable or tender
to palpation is within normal limits. A spleen that is 1 cm below the costal
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margin may be borderline enlarged, but a spleen that is 3 cm below the costal
margin is considered significantly enlarged.
A nurse is assessing a client with splenomegaly. Which of the following conditions
is most commonly associated with the development of splenomegaly?
a. Cirrhosis
b. Diabetes mellitus
c. Hypertension
d. Rheumatoid arthritis
a. Cirrhosis
Rationale: Cirrhosis is the most common condition associated with the
development of splenomegaly, accounting for approximately 60-70% of cases.
Other conditions that may lead to splenomegaly include infectious diseases,
such as mononucleosis, and blood disorders, such as sickle cell anemia. Diabetes
mellitus, hypertension, and rheumatoid arthritis are not typically associated
with the development of splenomegaly.
A nurse is assessing a client with hemorrhoids. Which of the following findings
would the nurse expect to observe?
a. Painful urination
b. Itching and burning in the anal area
c. Nausea and vomiting
d. Shortness of breath
Answer: b. Itching and burning in the anal area
Rationale: Hemorrhoids are swollen veins in the anal area that can cause
symptoms such as itching, burning, and pain. Nausea, vomiting, and shortness
of breath are not typically associated with hemorrhoids.
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