PNR 206/PNR206 Exam 4 V1 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is in the early stages of cirrhosis. Which of the following
clinical findings should the nurse expect?
A. Splenomegaly
B. Ascites
C. Fetor hepaticus
D. Enlarged liver
Correct Answer: D
Explanation: In the early stages of cirrhosis, the liver is typically enlarged and firm due to
inflammation and fatty infiltration. As the disease progresses to late-stage cirrhosis, the
liver becomes small and nodular because of extensive scarring. Ascites and fetor hepaticus
are generally considered late-stage manifestations of liver failure.
2. A nurse is reinforcing teaching with a client who has GERD about lifestyle modifications.
Which of the following instructions should the nurse include?
A. Wait at least 3 hours after eating before lying down.
B. Eat a large meal before bedtime to neutralize acid.
C. Drink carbonated beverages to reduce bloating.
D. Wear tight-fitting clothing to support the abdomen.
,Correct Answer: A
Explanation: Reflux of gastric contents is more likely to occur when the client lies flat soon
after eating because gravity no longer helps keep food in the stomach. Waiting at least 3
hours allows the stomach to empty, reducing the risk of acid backflow into the esophagus.
Tight-fitting clothes and large meals increase intra-abdominal pressure, which exacerbates
GERD symptoms.
3. A client with a history of Peptic Ulcer Disease (PUD) reports sudden, severe abdominal pain
and a rigid, board-like abdomen. What is the priority nursing action?
A. Notify the healthcare provider immediately.
B. Place the client in a supine position.
C. Administer an antacid as prescribed.
D. Assess the client’s bowel sounds for 5 minutes.
Correct Answer: A
Explanation: A rigid, board-like abdomen is a classic sign of gastrointestinal perforation,
which is a medical emergency. This condition leads to peritonitis due to the leakage of
gastric or intestinal contents into the peritoneal cavity. Immediate surgical intervention is
often required to repair the perforation and prevent sepsis.
4. A nurse is assessing a client for Cholecystitis. Which of the following physical assessment
techniques should the nurse use to identify Murphy’s sign?
A. Palpating the right upper quadrant during deep inspiration.
, B. Percussing the left upper quadrant for dullness.
C. Assessing for rebound tenderness in the lower left quadrant.
D. Checking for flank pain upon percussion (CVA tenderness).
Correct Answer: A
Explanation: Murphy’s sign is positive when a client experiences sharp pain that causes
them to hold their breath while the nurse palpates the right upper quadrant under the
costal margin. This sign is highly indicative of acute cholecystitis, as the inflamed
gallbladder comes into contact with the examiner’s hand during inspiration. Other
techniques like CVA tenderness are used to assess for kidney issues rather than gallbladder
inflammation.
5. A client is diagnosed with Diverticulitis and is currently in the acute phase of inflammation.
Which diet should the nurse expect to be ordered?
A. High-fiber diet with whole grains
B. High-protein, high-calorie diet
C. Low-residue or clear liquid diet
D. Fat-restricted diet
Correct Answer: C
Explanation: During the acute phase of diverticulitis, the bowel needs rest to allow
inflammation to subside. A low-residue or clear liquid diet reduces the amount of stool
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is in the early stages of cirrhosis. Which of the following
clinical findings should the nurse expect?
A. Splenomegaly
B. Ascites
C. Fetor hepaticus
D. Enlarged liver
Correct Answer: D
Explanation: In the early stages of cirrhosis, the liver is typically enlarged and firm due to
inflammation and fatty infiltration. As the disease progresses to late-stage cirrhosis, the
liver becomes small and nodular because of extensive scarring. Ascites and fetor hepaticus
are generally considered late-stage manifestations of liver failure.
2. A nurse is reinforcing teaching with a client who has GERD about lifestyle modifications.
Which of the following instructions should the nurse include?
A. Wait at least 3 hours after eating before lying down.
B. Eat a large meal before bedtime to neutralize acid.
C. Drink carbonated beverages to reduce bloating.
D. Wear tight-fitting clothing to support the abdomen.
,Correct Answer: A
Explanation: Reflux of gastric contents is more likely to occur when the client lies flat soon
after eating because gravity no longer helps keep food in the stomach. Waiting at least 3
hours allows the stomach to empty, reducing the risk of acid backflow into the esophagus.
Tight-fitting clothes and large meals increase intra-abdominal pressure, which exacerbates
GERD symptoms.
3. A client with a history of Peptic Ulcer Disease (PUD) reports sudden, severe abdominal pain
and a rigid, board-like abdomen. What is the priority nursing action?
A. Notify the healthcare provider immediately.
B. Place the client in a supine position.
C. Administer an antacid as prescribed.
D. Assess the client’s bowel sounds for 5 minutes.
Correct Answer: A
Explanation: A rigid, board-like abdomen is a classic sign of gastrointestinal perforation,
which is a medical emergency. This condition leads to peritonitis due to the leakage of
gastric or intestinal contents into the peritoneal cavity. Immediate surgical intervention is
often required to repair the perforation and prevent sepsis.
4. A nurse is assessing a client for Cholecystitis. Which of the following physical assessment
techniques should the nurse use to identify Murphy’s sign?
A. Palpating the right upper quadrant during deep inspiration.
, B. Percussing the left upper quadrant for dullness.
C. Assessing for rebound tenderness in the lower left quadrant.
D. Checking for flank pain upon percussion (CVA tenderness).
Correct Answer: A
Explanation: Murphy’s sign is positive when a client experiences sharp pain that causes
them to hold their breath while the nurse palpates the right upper quadrant under the
costal margin. This sign is highly indicative of acute cholecystitis, as the inflamed
gallbladder comes into contact with the examiner’s hand during inspiration. Other
techniques like CVA tenderness are used to assess for kidney issues rather than gallbladder
inflammation.
5. A client is diagnosed with Diverticulitis and is currently in the acute phase of inflammation.
Which diet should the nurse expect to be ordered?
A. High-fiber diet with whole grains
B. High-protein, high-calorie diet
C. Low-residue or clear liquid diet
D. Fat-restricted diet
Correct Answer: C
Explanation: During the acute phase of diverticulitis, the bowel needs rest to allow
inflammation to subside. A low-residue or clear liquid diet reduces the amount of stool
