Correct Questions & Rationales
tympany - ---✔✔✔ANSWER----A student is performing a physical
assessment on a patient. While assessing the abdomen, the student percusses the
spleen. What sound would be normal for the student to hear?
appendicitis - ---✔✔✔ANSWER----An emergency department nurse is
caring for a 17 year old patient who has severe pain in the umbilical area.
Documentation shows that the patient exhibits "Rovsing's sign." What might this
patient's medical diagnosis be?
shingles (herpes zoster) - ---✔✔✔ANSWER----When assessing a clinic
patient, the nurse asks if the patient has ever had varicella. The nurse knows that
varicella always precedes what?
partial intestinal obstruction - ---✔✔✔ANSWER----While auscultating a
patient's abdomen, the student notes abnormal bowel sounds. The nurse's preceptor
asks the student to describe the sounds. The student describes them as high-
, pitched, rushing sounds. The preceptor, an experienced nurse, would know that
these sounds indicate what?
colorectal cancer, food-borne illness, and hepatitis - ---✔✔✔ANSWER----
What does Healthy People have as its focus areas for the GI tract? (Mark all that
apply.)
the fracture crosses the part of the bone where the bone lengthens - ---
✔✔✔ANSWER----A 13-year-old boy is brought to the emergency
department with an injury to his left ankle after a skateboard accident. Diagnostic
films show a fracture across the epiphyses. The doctor explains that the patient
may not have full ROM and that his left leg may be shorter than his right leg. The
parents ask why one leg may be shorter than the other. What would be the nurse's
best answer?
trendelenberg test - ---✔✔✔ANSWER----A 3-month-old girl has been
diagnosed with congenital hip dislocation. What is a confirmatory test for this
disease?
use environmental cues - ---✔✔✔ANSWER----A patient is admitted to the
unit. The nurse notes that the medical record for this patient lists a fall risk of 75%
per the Morris Fall Risk scale. What would be an appropriate nursing intervention?
C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and
trapezius muscles fully developed, symmetrical and nontender - ---
✔✔✔ANSWER----A nurse has just finished assessing a patient's spine and
neck muscles. How would the nurse document normal findings?