NSG 3160 Exam 4 | NSG 3160 Health Assessment |
Actual Q&A with Rationale (NSG 3160 Exam 4) |
Galen
1. A nurse is assessing a patient with abdominal pain. The patient points to the right
upper quadrant. Which organs are most likely involved?
a) Cecum and appendix
b) Stomach and spleen
c) Liver and gallbladder
d) Sigmoid colon and left ovary
Correct Answer: c) Liver and gallbladder
Rationale: The right upper quadrant contains the liver, gallbladder, duodenum, head of
pancreas, right kidney, and hepatic flexure of the colon. The cecum and appendix are in
the right lower quadrant, the stomach and spleen are in the left upper quadrant, and the
sigmoid colon and left ovary are in the left lower quadrant.
2. During an abdominal assessment, the nurse auscultates before percussion and
palpation. What is the primary reason for this sequence?
a) To avoid causing pain
b) To prevent distortion of bowel sounds
c) To assess for masses first
d) To ensure patient comfort
Correct Answer: b) To prevent distortion of bowel sounds
Rationale: Percussion and palpation can increase peristalsis, which would alter bowel
sounds and give a false interpretation. Auscultation is performed first to obtain
accurate baseline bowel sounds.
3. A patient reports black, tarry stools. The nurse understands this is most likely due
to:
a) Iron supplementation
b) Upper gastrointestinal bleeding
c) Hemorrhoids
d) Bile obstruction
Correct Answer: b) Upper gastrointestinal bleeding
Rationale: Melena (black, tarry stools) is caused by occult blood from an upper GI
bleed. Iron supplements can cause black, non-tarry stools. Bright red blood suggests
lower GI bleeding or hemorrhoids. Clay-colored stools indicate bile obstruction.
, 4. Which percussion note is normally predominant over the abdomen?
a) Dullness
b) Tympany
c) Hyperresonance
d) Flatness*
Correct Answer: b) Tympany
Rationale: Tympany predominates because air in the intestines rises to the surface
when the patient is supraenous. Dulness is heard over solid organs like the liver;
hyperresonance occurs with gaseous distention; flatness is heard over solids.
5. A nurse is assessing a patient for constipation using the Rome III criteria. Which
finding is consistent with this diagnosis?
a) Three stools per day
b) Straining during bowel movements
c) Soft, formed stools
d) Sensation of complete evacuation
Correct Answer: b) Straining during bowel movements
Rationale: Rome III criteria for constipation include ≤3 stools per week, straining,
lumpy/hard stools, sensation of incomplete evacuation, and sensation of blockage.
Straining is a key symptom; 3 per day is normal; soft stools are not constipation.
6. Which organ is NOT normally palpable on abdominal examination?
a) Liver edge
b) Right kidney
c) Spleen
d) Aortic pulsation
Correct Answer: c) Spleen
Rationale:: The spleen is normally NOT palpable and must be enlarged three times its
normal size to be felt. The liver edge may be felt on inspiration, the right kidney is
sometimes palpable, and the aortic pulsation is often felt in thin individials.
7. A patient with an enlarged spleen should be palpated with caution because:
a) The spleen is located in the RUQ
b) An enlarged spleen can rupture easily
c) The spleen is always painful
Actual Q&A with Rationale (NSG 3160 Exam 4) |
Galen
1. A nurse is assessing a patient with abdominal pain. The patient points to the right
upper quadrant. Which organs are most likely involved?
a) Cecum and appendix
b) Stomach and spleen
c) Liver and gallbladder
d) Sigmoid colon and left ovary
Correct Answer: c) Liver and gallbladder
Rationale: The right upper quadrant contains the liver, gallbladder, duodenum, head of
pancreas, right kidney, and hepatic flexure of the colon. The cecum and appendix are in
the right lower quadrant, the stomach and spleen are in the left upper quadrant, and the
sigmoid colon and left ovary are in the left lower quadrant.
2. During an abdominal assessment, the nurse auscultates before percussion and
palpation. What is the primary reason for this sequence?
a) To avoid causing pain
b) To prevent distortion of bowel sounds
c) To assess for masses first
d) To ensure patient comfort
Correct Answer: b) To prevent distortion of bowel sounds
Rationale: Percussion and palpation can increase peristalsis, which would alter bowel
sounds and give a false interpretation. Auscultation is performed first to obtain
accurate baseline bowel sounds.
3. A patient reports black, tarry stools. The nurse understands this is most likely due
to:
a) Iron supplementation
b) Upper gastrointestinal bleeding
c) Hemorrhoids
d) Bile obstruction
Correct Answer: b) Upper gastrointestinal bleeding
Rationale: Melena (black, tarry stools) is caused by occult blood from an upper GI
bleed. Iron supplements can cause black, non-tarry stools. Bright red blood suggests
lower GI bleeding or hemorrhoids. Clay-colored stools indicate bile obstruction.
, 4. Which percussion note is normally predominant over the abdomen?
a) Dullness
b) Tympany
c) Hyperresonance
d) Flatness*
Correct Answer: b) Tympany
Rationale: Tympany predominates because air in the intestines rises to the surface
when the patient is supraenous. Dulness is heard over solid organs like the liver;
hyperresonance occurs with gaseous distention; flatness is heard over solids.
5. A nurse is assessing a patient for constipation using the Rome III criteria. Which
finding is consistent with this diagnosis?
a) Three stools per day
b) Straining during bowel movements
c) Soft, formed stools
d) Sensation of complete evacuation
Correct Answer: b) Straining during bowel movements
Rationale: Rome III criteria for constipation include ≤3 stools per week, straining,
lumpy/hard stools, sensation of incomplete evacuation, and sensation of blockage.
Straining is a key symptom; 3 per day is normal; soft stools are not constipation.
6. Which organ is NOT normally palpable on abdominal examination?
a) Liver edge
b) Right kidney
c) Spleen
d) Aortic pulsation
Correct Answer: c) Spleen
Rationale:: The spleen is normally NOT palpable and must be enlarged three times its
normal size to be felt. The liver edge may be felt on inspiration, the right kidney is
sometimes palpable, and the aortic pulsation is often felt in thin individials.
7. A patient with an enlarged spleen should be palpated with caution because:
a) The spleen is located in the RUQ
b) An enlarged spleen can rupture easily
c) The spleen is always painful
