NR 509 Final Exam Study Guide
1. Chapter 19: Abdomen: ...
2. An overweight 26-year-old public servant presents to the Emergency
Department with 12 hours of intense abdominal pain, light-headedness, and
a fainting episode that finally prompted her to seek medical attention. She
has a strong family history of gallstones and is concerned about this
possibility. She has not had any vomiting or diarrhea. She had a normal
bowel movement this morning. Her ²-human chorionic gonadotropin (²-
hCG) is positive at triage. She reports that her last period was 10 weeks
ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68;
respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC
orally. The clinician performs an abdominal exam prior to her pelvic exam
and, on palpation of her abdomen, finds involuntary rigidity and rebound
tenderness. What is the most likely diagnosis?: a. Ruptured tubal (or ectopic)
pregnancy b. Acute cholecystitis
c. Ruptured appendix
d. Perforated bowel wall
e. Ruptured ovarian cyst
3. A 63-year-old janitor with a history of adenomatous colonic polyps presents
for a well visit. Basic labs are performed to screen for diabetes mellitus and
dyslipidemia. Electrolytes and liver enzymes were also measured. His labs
are all normal expect for moderate elevations of aspartate aminotransferase,
alanine aminotransferase, -³glutamyl transferase, and alkaline phosphatase
as well as a mildly elevated total bilirubin. He presents for a follow-up
appointment and the clinician performs an abdominal exam to assess his
liver. Which of the following findings would be most consistent with
hepatomegaly?: a. Liver span of 11 cm at the midclavicular line b. Liver span of 8
cm at the midsternal line
c. Dullness to percussion over a span of 11 cm at the midclavicular line
d. Dullness to percussion over a span of 8 cm at the midsternal line
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration4. A 63-year-old underweight administrative clerk with a 50-pack-
year smoking history presents with a several month history of recurrent
epigastric abdominal discomfort. She feels fairly well otherwise and
denies any nausea, vomiting, diarrhea, or constipation. She reports that a
, NR 509 Final Exam Study Guide
first cousin died from a ruptured aneurysm at age 68 years. Her vital signs
are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen
saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On
exam, her abdominal aorta is prominent, which is concerning for an
abdominal aortic aneurysm (AAA).
Which of the following is her most significant risk factor for an AAA?:
a. Female gender
b. History of smoking
c. Underweight
d. Family history of ruptured aneurysm
e. Hypertension
5. A 76-year-old retired man with a history of prostate cancer and
hypertension has been screened annually for colon cancer using high
sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his
hypertension, during which the clinician scans his chart to ensure he is up to
date with his preventive health care. He has a positive FOBT on one occasion
at age 66 years and subsequently went for a colonoscopy. Internal
hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no
first-degree relatives with a history of colorectal cancer or adenomatous
polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening
recommendations for this patient?: a. Do not screen routinely
b. Continue annual FOBT screening until age 80 years
c. Continue annual FOBT screening until age 85 years
d. Repeat colonoscopy this year
e. Sigmoidoscopy every 5 years with FOBT every 3 years
Submit
6. An otherwise healthy 31-year-old accountant presents to an outpatient
clinic with a 3-year history of recurrent crampy abdominal pain that lasts for
about 1-2 weeks each episode and is associated with onset of constipation.
She describes infrequent, small hard stool that she finds very difficult to pass.
She has tried to increase dietary fiber and water intake, but usually this is not
sufficient and she resorts to over-the-counter laxatives, which she finds upset
her stomach but do resolve the constipation. Symptoms typically gradually
resolve with bowel movements. Which of the following is the most likely
, NR 509 Final Exam Study Guide
physiological mechanism for her constipation?: a. A large, firm fecal mass in
the rectum
b. Decreased fecal bulk
c. Functional change in bowel movement
d. Spasm of the external sphincter
e. Impairment of autonomic innervations
7. A 23-year-old woman comes to the respirology clinic for follow-up of her
chronic sinusitis and bronchiectasis that is associated with a rare congenital
condition called Kartagener syndrome. The preceptor notes that she has situs
inversus and asks for a physical exam. Which of the following descriptions
best fits with findings on the abdominal exam?: a. Tympany to percussion in the
right upper quadrant, dullness to percussion of the left upper quadrant
b. Protuberant abdomen that has scattered areas of tympany and dullness;
stool is felt on palpation
c. Liver dullness in the right upper quadrant that is displaced downward by the
low diaphragm due to chronic obstructive pulmonary disease
d. Dullness to percussion of the left lower anterior chest wall roughly at the
anterior axillary line
e. A change in percussion from tympany to dullness in the left lower anterior
chest wall on inspiration
8. An otherwise healthy 28-year-old lawyer presents to the Emergency
Department with a 1-day history of severe abdominal pain. The emergency
physician suspects appendicitis and general surgery is consulted. The
resident believes the patient has signs of peritonitis on exam. Which of the
following physical exam findings supports peritonitis?: a. Voluntary
contraction of the abdominal wall that persists over several examinations
b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand
quickly produces pain
c. Abdominal pain that increases with hip flexion
d. Localized pain over McBurney point, which lies 2 inches from the anterior
superior iliac spinous process on a line drawn from the umbilicus e. Pain with
internal rotation of the right hip
9. A 58-year-old man with a history of diabetes and alcohol addiction has been
sober for the last 10 months. He presents with a 4-month history of increasing
, NR 509 Final Exam Study Guide
weakness, recurrent epigastric pain radiating to his back, chronic diarrhea
with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is
the mechanism of his most likely diagnosis?: a. Helicobacter pylori infection b.
Inflammation of the gallbladder
c. Inflammation of colonic diverticulum
d. Reduced blood supply to the bowel
e. Fibrosis of the pancreas
10. A 46-year-old executive who is obese and otherwise healthy presents to
a family medicine clinic with a 3-month course of recurrent severe
abdominal pain that usually resolves on its own after a few hours. Her last
episode was prolonged lasting 6 hours, and she is frustrated that she has
had to leave or miss work on three separate occasions. She would like a
diagnosis and the problem fixed. Which symptoms or signs would be most
suggestive of a diagnosis of biliary colic?: a. Exacerbating factor includes
alcohol intake b. Positive McBurney point tenderness
c. Poorly localized periumbilical pain
d. Vomiting of bile
e. Associated right shoulder pain
11. Chapter 22 Anus, Rectum, and Prostate:
12. A 49-year-old male nurse experiences fecal incontinence after a motor
vehicle accident that left him paralyzed below the waist. He asks his
rehabilitation physician about the control of this function in a person
without his injuries. Which of the following is true regarding the muscle
control of the anal sphincter?: a. The internal anal sphincter is under
voluntary control, whereas the external anal sphincter is under involuntary
control.
b. The internal anal sphincter is under involuntary control, whereas the external
anal sphincter is under voluntary control.
c. Both internal and external anal sphincter are under voluntary control.
d. Both internal and external anal sphincter are under involuntary control.
e. Control of the anal sphincters is variable between individuals
13. A 62-year-old male who is undergoing evaluation for possible prostate
cancer strongly declines a rectal examination, stating that, "Some trainee
once did that and it hurt badly." Which of the following is true about the
innervation of the anus and rectum that may explain this patient's experience
1. Chapter 19: Abdomen: ...
2. An overweight 26-year-old public servant presents to the Emergency
Department with 12 hours of intense abdominal pain, light-headedness, and
a fainting episode that finally prompted her to seek medical attention. She
has a strong family history of gallstones and is concerned about this
possibility. She has not had any vomiting or diarrhea. She had a normal
bowel movement this morning. Her ²-human chorionic gonadotropin (²-
hCG) is positive at triage. She reports that her last period was 10 weeks
ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68;
respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC
orally. The clinician performs an abdominal exam prior to her pelvic exam
and, on palpation of her abdomen, finds involuntary rigidity and rebound
tenderness. What is the most likely diagnosis?: a. Ruptured tubal (or ectopic)
pregnancy b. Acute cholecystitis
c. Ruptured appendix
d. Perforated bowel wall
e. Ruptured ovarian cyst
3. A 63-year-old janitor with a history of adenomatous colonic polyps presents
for a well visit. Basic labs are performed to screen for diabetes mellitus and
dyslipidemia. Electrolytes and liver enzymes were also measured. His labs
are all normal expect for moderate elevations of aspartate aminotransferase,
alanine aminotransferase, -³glutamyl transferase, and alkaline phosphatase
as well as a mildly elevated total bilirubin. He presents for a follow-up
appointment and the clinician performs an abdominal exam to assess his
liver. Which of the following findings would be most consistent with
hepatomegaly?: a. Liver span of 11 cm at the midclavicular line b. Liver span of 8
cm at the midsternal line
c. Dullness to percussion over a span of 11 cm at the midclavicular line
d. Dullness to percussion over a span of 8 cm at the midsternal line
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration4. A 63-year-old underweight administrative clerk with a 50-pack-
year smoking history presents with a several month history of recurrent
epigastric abdominal discomfort. She feels fairly well otherwise and
denies any nausea, vomiting, diarrhea, or constipation. She reports that a
, NR 509 Final Exam Study Guide
first cousin died from a ruptured aneurysm at age 68 years. Her vital signs
are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen
saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On
exam, her abdominal aorta is prominent, which is concerning for an
abdominal aortic aneurysm (AAA).
Which of the following is her most significant risk factor for an AAA?:
a. Female gender
b. History of smoking
c. Underweight
d. Family history of ruptured aneurysm
e. Hypertension
5. A 76-year-old retired man with a history of prostate cancer and
hypertension has been screened annually for colon cancer using high
sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his
hypertension, during which the clinician scans his chart to ensure he is up to
date with his preventive health care. He has a positive FOBT on one occasion
at age 66 years and subsequently went for a colonoscopy. Internal
hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no
first-degree relatives with a history of colorectal cancer or adenomatous
polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening
recommendations for this patient?: a. Do not screen routinely
b. Continue annual FOBT screening until age 80 years
c. Continue annual FOBT screening until age 85 years
d. Repeat colonoscopy this year
e. Sigmoidoscopy every 5 years with FOBT every 3 years
Submit
6. An otherwise healthy 31-year-old accountant presents to an outpatient
clinic with a 3-year history of recurrent crampy abdominal pain that lasts for
about 1-2 weeks each episode and is associated with onset of constipation.
She describes infrequent, small hard stool that she finds very difficult to pass.
She has tried to increase dietary fiber and water intake, but usually this is not
sufficient and she resorts to over-the-counter laxatives, which she finds upset
her stomach but do resolve the constipation. Symptoms typically gradually
resolve with bowel movements. Which of the following is the most likely
, NR 509 Final Exam Study Guide
physiological mechanism for her constipation?: a. A large, firm fecal mass in
the rectum
b. Decreased fecal bulk
c. Functional change in bowel movement
d. Spasm of the external sphincter
e. Impairment of autonomic innervations
7. A 23-year-old woman comes to the respirology clinic for follow-up of her
chronic sinusitis and bronchiectasis that is associated with a rare congenital
condition called Kartagener syndrome. The preceptor notes that she has situs
inversus and asks for a physical exam. Which of the following descriptions
best fits with findings on the abdominal exam?: a. Tympany to percussion in the
right upper quadrant, dullness to percussion of the left upper quadrant
b. Protuberant abdomen that has scattered areas of tympany and dullness;
stool is felt on palpation
c. Liver dullness in the right upper quadrant that is displaced downward by the
low diaphragm due to chronic obstructive pulmonary disease
d. Dullness to percussion of the left lower anterior chest wall roughly at the
anterior axillary line
e. A change in percussion from tympany to dullness in the left lower anterior
chest wall on inspiration
8. An otherwise healthy 28-year-old lawyer presents to the Emergency
Department with a 1-day history of severe abdominal pain. The emergency
physician suspects appendicitis and general surgery is consulted. The
resident believes the patient has signs of peritonitis on exam. Which of the
following physical exam findings supports peritonitis?: a. Voluntary
contraction of the abdominal wall that persists over several examinations
b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand
quickly produces pain
c. Abdominal pain that increases with hip flexion
d. Localized pain over McBurney point, which lies 2 inches from the anterior
superior iliac spinous process on a line drawn from the umbilicus e. Pain with
internal rotation of the right hip
9. A 58-year-old man with a history of diabetes and alcohol addiction has been
sober for the last 10 months. He presents with a 4-month history of increasing
, NR 509 Final Exam Study Guide
weakness, recurrent epigastric pain radiating to his back, chronic diarrhea
with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is
the mechanism of his most likely diagnosis?: a. Helicobacter pylori infection b.
Inflammation of the gallbladder
c. Inflammation of colonic diverticulum
d. Reduced blood supply to the bowel
e. Fibrosis of the pancreas
10. A 46-year-old executive who is obese and otherwise healthy presents to
a family medicine clinic with a 3-month course of recurrent severe
abdominal pain that usually resolves on its own after a few hours. Her last
episode was prolonged lasting 6 hours, and she is frustrated that she has
had to leave or miss work on three separate occasions. She would like a
diagnosis and the problem fixed. Which symptoms or signs would be most
suggestive of a diagnosis of biliary colic?: a. Exacerbating factor includes
alcohol intake b. Positive McBurney point tenderness
c. Poorly localized periumbilical pain
d. Vomiting of bile
e. Associated right shoulder pain
11. Chapter 22 Anus, Rectum, and Prostate:
12. A 49-year-old male nurse experiences fecal incontinence after a motor
vehicle accident that left him paralyzed below the waist. He asks his
rehabilitation physician about the control of this function in a person
without his injuries. Which of the following is true regarding the muscle
control of the anal sphincter?: a. The internal anal sphincter is under
voluntary control, whereas the external anal sphincter is under involuntary
control.
b. The internal anal sphincter is under involuntary control, whereas the external
anal sphincter is under voluntary control.
c. Both internal and external anal sphincter are under voluntary control.
d. Both internal and external anal sphincter are under involuntary control.
e. Control of the anal sphincters is variable between individuals
13. A 62-year-old male who is undergoing evaluation for possible prostate
cancer strongly declines a rectal examination, stating that, "Some trainee
once did that and it hurt badly." Which of the following is true about the
innervation of the anus and rectum that may explain this patient's experience
