,NSG3160/NSG 3160 Exam 4 | Health Assessment |
1. Which of the following is the correct sequence of techniques for an abdominal assessment?
A) Inspection, palpation, percussion, auscultation
B) Auscultation, inspection, palpation, percussion
C) Inspection, auscultation, percussion, palpation
D) Palpation, percussion, inspection, auscultation
Correct Answer: Inspection, auscultation, percussion, palpation
Rationale: The abdominal assessment sequence is inspection, auscultation, percussion, and palpation.
This modified order prevents palpation and percussion from altering bowel sounds before
auscultation. Auscultation is performed before palpation to ensure accurate assessment of bowel
sounds.
2. A nurse is auscultating a patient's abdomen and notes bowel sounds that are high-pitched, gurgling,
and occur approximately 5 to 30 times per minute. How should this finding be documented?
A) Hypoactive bowel sounds
B) Normoactive bowel sounds
C) Hyperactive bowel sounds
D) Absent bowel sounds
Correct Answer: Normoactive bowel sounds
Rationale: Normoactive bowel sounds are characterized by high-pitched, gurgling, cascading sounds
occurring 5 to 30 times per minute. Hypoactive sounds are fewer than 5 per minute, hyperactive
sounds are greater than 30 per minute, and absent bowel sounds require listening for 5 minutes per
quadrant.
3. During an abdominal inspection, the nurse observes visible, wavelike movements across the
patient's abdomen. This finding is most consistent with which condition?
A) Normal peristalsis
,B) Intestinal obstruction
C) Ascites
D) Organomegaly
Correct Answer: Intestinal obstruction
Rationale: Visible peristaltic waves suggest increased peristalsis attempting to overcome a blockage,
which is often seen in intestinal obstruction. These waves are not a normal finding in adults. Ascites
presents with a distended, taut abdomen, and organomegaly would not produce visible peristaltic
waves.
4. When assessing a patient for possible absent bowel sounds, how long should the nurse listen in
each quadrant before documenting absence?
A) 1 minute
B) 2 minutes
C) 3 minutes
D) 5 minutes
Correct Answer: 5 minutes
Rationale: To confirm absent bowel sounds, the nurse must listen for a full 5 minutes in each
quadrant. Briefer listening periods may miss intermittent sounds and result in an inaccurate
assessment of a silent abdomen.
5. The nurse is preparing to percuss the abdomen and hears a loud, drum-like sound over most of the
area. How should the nurse document this finding?
A) Flatness
B) Dullness
C) Resonance
D) Tympany
, Correct Answer: Tympany
Rationale: Tympany is the predominant sound heard over the abdomen due to the presence of air in
the stomach and intestines. Dullness is heard over solid organs such as the liver, resonance is heard
over normal lung tissue, and flatness is heard over bone or muscle.
6. Which organ is located in the right upper quadrant of the abdomen?
A) Spleen
B) Sigmoid colon
C) Appendix
D) Liver
Correct Answer: Liver
Rationale: The liver occupies most of the right upper quadrant (RUQ). The spleen is located in the left
upper quadrant, the sigmoid colon in the left lower quadrant, and the appendix in the right lower
quadrant.
7. A patient reports having black, tarry stools. The nurse should document this finding as:
A) Hematochezia
B) Steatorrhea
C) Melena
D) Occult blood
Correct Answer: Melena
Rationale: Melena refers to black, tarry, sticky stools caused by the digestion of blood in the
gastrointestinal tract, usually from an upper GI source such as the stomach or duodenum.
Hematochezia is bright red blood per rectum, steatorrhea is fatty, foul-smelling stools, and occult
blood is not visible to the naked eye.
1. Which of the following is the correct sequence of techniques for an abdominal assessment?
A) Inspection, palpation, percussion, auscultation
B) Auscultation, inspection, palpation, percussion
C) Inspection, auscultation, percussion, palpation
D) Palpation, percussion, inspection, auscultation
Correct Answer: Inspection, auscultation, percussion, palpation
Rationale: The abdominal assessment sequence is inspection, auscultation, percussion, and palpation.
This modified order prevents palpation and percussion from altering bowel sounds before
auscultation. Auscultation is performed before palpation to ensure accurate assessment of bowel
sounds.
2. A nurse is auscultating a patient's abdomen and notes bowel sounds that are high-pitched, gurgling,
and occur approximately 5 to 30 times per minute. How should this finding be documented?
A) Hypoactive bowel sounds
B) Normoactive bowel sounds
C) Hyperactive bowel sounds
D) Absent bowel sounds
Correct Answer: Normoactive bowel sounds
Rationale: Normoactive bowel sounds are characterized by high-pitched, gurgling, cascading sounds
occurring 5 to 30 times per minute. Hypoactive sounds are fewer than 5 per minute, hyperactive
sounds are greater than 30 per minute, and absent bowel sounds require listening for 5 minutes per
quadrant.
3. During an abdominal inspection, the nurse observes visible, wavelike movements across the
patient's abdomen. This finding is most consistent with which condition?
A) Normal peristalsis
,B) Intestinal obstruction
C) Ascites
D) Organomegaly
Correct Answer: Intestinal obstruction
Rationale: Visible peristaltic waves suggest increased peristalsis attempting to overcome a blockage,
which is often seen in intestinal obstruction. These waves are not a normal finding in adults. Ascites
presents with a distended, taut abdomen, and organomegaly would not produce visible peristaltic
waves.
4. When assessing a patient for possible absent bowel sounds, how long should the nurse listen in
each quadrant before documenting absence?
A) 1 minute
B) 2 minutes
C) 3 minutes
D) 5 minutes
Correct Answer: 5 minutes
Rationale: To confirm absent bowel sounds, the nurse must listen for a full 5 minutes in each
quadrant. Briefer listening periods may miss intermittent sounds and result in an inaccurate
assessment of a silent abdomen.
5. The nurse is preparing to percuss the abdomen and hears a loud, drum-like sound over most of the
area. How should the nurse document this finding?
A) Flatness
B) Dullness
C) Resonance
D) Tympany
, Correct Answer: Tympany
Rationale: Tympany is the predominant sound heard over the abdomen due to the presence of air in
the stomach and intestines. Dullness is heard over solid organs such as the liver, resonance is heard
over normal lung tissue, and flatness is heard over bone or muscle.
6. Which organ is located in the right upper quadrant of the abdomen?
A) Spleen
B) Sigmoid colon
C) Appendix
D) Liver
Correct Answer: Liver
Rationale: The liver occupies most of the right upper quadrant (RUQ). The spleen is located in the left
upper quadrant, the sigmoid colon in the left lower quadrant, and the appendix in the right lower
quadrant.
7. A patient reports having black, tarry stools. The nurse should document this finding as:
A) Hematochezia
B) Steatorrhea
C) Melena
D) Occult blood
Correct Answer: Melena
Rationale: Melena refers to black, tarry, sticky stools caused by the digestion of blood in the
gastrointestinal tract, usually from an upper GI source such as the stomach or duodenum.
Hematochezia is bright red blood per rectum, steatorrhea is fatty, foul-smelling stools, and occult
blood is not visible to the naked eye.
