NUR 210 FINAL EXAM WITH CORRECT SOLUTIONS
1. infection - ANSWER-While assessing a client's abdomen, the nurse observes involuntary
reflex guarding on expiration. The nurse would interpret this as most likely indicating
what complication?
2. An increase in the pitch - ANSWER-Which change in auscultation of bowel sounds should
the nurse recognize as most diagnostic of an intestinal obstruction?
3. Ask the client to breathe slowly and deeply - ANSWER-The nurse is performing light
palpation of the client's abdomen. How can the nurse best prevent voluntary guarding
during this phase of assessment?
4. ureteral stone - ANSWER-Linda is a 29-year-old who had excruciating pain that started
under her lower ribs on the right side. The pain eventually moved to her lateral
abdomen and then into her right lower quadrant. Which is most likely given this
presentation?
5. "I should avoid lifting heavy objects." - ANSWER-The nurse provides teaching to a client
with gastroesophageal reflux disease (GERD). Which client statement indicates that
teaching has been effective?
6. Renal calculi
Kidney infection
Hydronephrosis - ANSWER-A client expresses pain when the left costovertebral angle is
palpated. What should the nurse suspect is occurring with this client? Select all that apply.
7. Cullen's sign - ANSWER-A nurse suspects intra-abdominal bleeding in a client who was
recently involved in a motor vehicle accident. Which finding would most likely lead the
nurse to this suspicion?
,8. absent - ANSWER-A young adult male who comes to the emergency department
complaining of abdominal pain for the past 3 days is suspected of having a ruptured
appendix. What bowel sound would the nurse expect to assess in this client?
9. Question the order as a barium enema is contraindicated in acute appendicitis -
ANSWER-The client with a acute appendicitis has been ordered a barium enema. What
should the nurse do first?
10. Ovarian tumor
Impacted colon
Uterine enlargement
Full bladder - ANSWER-A nurse observes the abdomen of a client and notices it to be
distended below the umbilicus. The nurse recognizes that this can be caused by which of
these conditions? Select all that apply.
11. Esophageal varices - ANSWER-A 46-year-old former salesman presents to the ER
complaining of black stools for the past few weeks. His past medical history is significant
for cirrhosis. He has gained weight recently, especially around his abdomen. He has
smoked two packs of cigarettes a day for 30 years and has drunk approximately 10
alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the
past. He denies any recent use. He is currently unemployed and has never been married.
Examination shows a man appearing older than his stated age. His skin has a yellowish
tint and he is thin with a prominent abdomen. Multiple "spider angiomas" are at the
base of his neck. Otherwise his heart and lung examinations are normal. On inspection
he has dilated veins around his umbilicus. Increased bowel sounds are heard during
auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric
area. His liver is small and hard to palpation and he has a positive fluid wave. He is
positive for occult blood on his rectal examination. What cause of black stools most likely
describes his symptoms and signs?
12. Gastroesophageal reflux - ANSWER-A client complains of abdominal pain that is
worsened when he lies on his back. The nurse should suspect which of the following as
the underlying cause?
,13. Ascites - ANSWER-The nurse has the client participate in the assessment technique
shown. For which health problem is the nurse assessing in this client?
14. Right side-lying - ANSWER-A nurse is preparing to palpate a client's spleen. Which
position should the nurse use to best facilitate palpation?
15. Acute pancreatitis - ANSWER-The client has epigastric pain that is poorly localized and
radiates to the back. What would be an important diagnosis to assess for?
16. Stop the palpation and notify the health care provider - ANSWER-A nurse performs light
palpation of the abdomen and feels a prominent, non-tender, pulsating mass above the
umbilicus that measures approximately six (6) centimeters. What is an appropriate
action by the nurse?
17. Murphy's sign - ANSWER-During the abdominal examination, a nurse presses her fingers
at the client's right costal margin and tells the client to inhale. At this point, the client
holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This
test is positive for which sign?
18. Bowel sounds normal - ANSWER-When conducting the physical examination of a client's
abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the
following statements would accurately describe this finding?
19. Gastric ulcer - ANSWER-A client complains of epigastric pain and tarry stools. The nurse
should suspect which of the following as the underlying cause?
20. Irritable bowel syndrome - ANSWER-Monique is a 33-year-old administrative assistant
who has had intermittent lower abdominal pain approximately one week a month for
the past year. It is not related to her menses. She notes relief with defecation, and a
, change in form and frequency of her bowel movements with these episodes. Which of
the following is most likely?
21. Sickle cell anemia - ANSWER-A shift report indicates that an African American client has
symptoms of both jaundice and splenomegaly. Considering the client's ethnicity and
diagnoses, what is the likely medical diagnosis?
22. "Do you take painkillers like aspirin on a regular basis?" - ANSWER-A client exhibits many
of the most common signs and symptoms of peptic ulcer disease. What interview
question addresses the most plausible cause of the client's health problem?
23. Constipation related to decrease in fluid intake - ANSWER-A college student presents to
the health care clinic with reports of no bowel movement for 4 days, bloating, and
generalized abdominal discomfort. She states that she has not been eating and drinking
correctly and is stressed because she has a final exam in 2 days. A nurse assesses the
abdomen and finds positive bowel sounds in all four quadrants and tenderness in the
left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas
sign are negative. What nursing diagnosis can the nurse confirm for this client?
24. body mass index greater than 30
25. taking multiple medications
26. hiatal hernia - ANSWER-A nurse suspects that a client has gastroesophageal reflux
disease (GERD). Which risk factors must be present for the nurse to confirm this? Select
all that apply.
27. Right upper quadrant
Costovertebral angles
Epigastrium - ANSWER-The nurse is admitting a client who is in hypertensive crisis. The
doctor's notes indicate that bruits that are both systolic and diastolic have been noted
and renal artery stenosis is suspected as the cause of the hypertension. Where would
the nurse auscultate the client's abdomen to hear these bruits? (Select all that apply.)
1. infection - ANSWER-While assessing a client's abdomen, the nurse observes involuntary
reflex guarding on expiration. The nurse would interpret this as most likely indicating
what complication?
2. An increase in the pitch - ANSWER-Which change in auscultation of bowel sounds should
the nurse recognize as most diagnostic of an intestinal obstruction?
3. Ask the client to breathe slowly and deeply - ANSWER-The nurse is performing light
palpation of the client's abdomen. How can the nurse best prevent voluntary guarding
during this phase of assessment?
4. ureteral stone - ANSWER-Linda is a 29-year-old who had excruciating pain that started
under her lower ribs on the right side. The pain eventually moved to her lateral
abdomen and then into her right lower quadrant. Which is most likely given this
presentation?
5. "I should avoid lifting heavy objects." - ANSWER-The nurse provides teaching to a client
with gastroesophageal reflux disease (GERD). Which client statement indicates that
teaching has been effective?
6. Renal calculi
Kidney infection
Hydronephrosis - ANSWER-A client expresses pain when the left costovertebral angle is
palpated. What should the nurse suspect is occurring with this client? Select all that apply.
7. Cullen's sign - ANSWER-A nurse suspects intra-abdominal bleeding in a client who was
recently involved in a motor vehicle accident. Which finding would most likely lead the
nurse to this suspicion?
,8. absent - ANSWER-A young adult male who comes to the emergency department
complaining of abdominal pain for the past 3 days is suspected of having a ruptured
appendix. What bowel sound would the nurse expect to assess in this client?
9. Question the order as a barium enema is contraindicated in acute appendicitis -
ANSWER-The client with a acute appendicitis has been ordered a barium enema. What
should the nurse do first?
10. Ovarian tumor
Impacted colon
Uterine enlargement
Full bladder - ANSWER-A nurse observes the abdomen of a client and notices it to be
distended below the umbilicus. The nurse recognizes that this can be caused by which of
these conditions? Select all that apply.
11. Esophageal varices - ANSWER-A 46-year-old former salesman presents to the ER
complaining of black stools for the past few weeks. His past medical history is significant
for cirrhosis. He has gained weight recently, especially around his abdomen. He has
smoked two packs of cigarettes a day for 30 years and has drunk approximately 10
alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the
past. He denies any recent use. He is currently unemployed and has never been married.
Examination shows a man appearing older than his stated age. His skin has a yellowish
tint and he is thin with a prominent abdomen. Multiple "spider angiomas" are at the
base of his neck. Otherwise his heart and lung examinations are normal. On inspection
he has dilated veins around his umbilicus. Increased bowel sounds are heard during
auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric
area. His liver is small and hard to palpation and he has a positive fluid wave. He is
positive for occult blood on his rectal examination. What cause of black stools most likely
describes his symptoms and signs?
12. Gastroesophageal reflux - ANSWER-A client complains of abdominal pain that is
worsened when he lies on his back. The nurse should suspect which of the following as
the underlying cause?
,13. Ascites - ANSWER-The nurse has the client participate in the assessment technique
shown. For which health problem is the nurse assessing in this client?
14. Right side-lying - ANSWER-A nurse is preparing to palpate a client's spleen. Which
position should the nurse use to best facilitate palpation?
15. Acute pancreatitis - ANSWER-The client has epigastric pain that is poorly localized and
radiates to the back. What would be an important diagnosis to assess for?
16. Stop the palpation and notify the health care provider - ANSWER-A nurse performs light
palpation of the abdomen and feels a prominent, non-tender, pulsating mass above the
umbilicus that measures approximately six (6) centimeters. What is an appropriate
action by the nurse?
17. Murphy's sign - ANSWER-During the abdominal examination, a nurse presses her fingers
at the client's right costal margin and tells the client to inhale. At this point, the client
holds his breath as a result of experiencing a sharp pain where the nurse is pressing. This
test is positive for which sign?
18. Bowel sounds normal - ANSWER-When conducting the physical examination of a client's
abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the
following statements would accurately describe this finding?
19. Gastric ulcer - ANSWER-A client complains of epigastric pain and tarry stools. The nurse
should suspect which of the following as the underlying cause?
20. Irritable bowel syndrome - ANSWER-Monique is a 33-year-old administrative assistant
who has had intermittent lower abdominal pain approximately one week a month for
the past year. It is not related to her menses. She notes relief with defecation, and a
, change in form and frequency of her bowel movements with these episodes. Which of
the following is most likely?
21. Sickle cell anemia - ANSWER-A shift report indicates that an African American client has
symptoms of both jaundice and splenomegaly. Considering the client's ethnicity and
diagnoses, what is the likely medical diagnosis?
22. "Do you take painkillers like aspirin on a regular basis?" - ANSWER-A client exhibits many
of the most common signs and symptoms of peptic ulcer disease. What interview
question addresses the most plausible cause of the client's health problem?
23. Constipation related to decrease in fluid intake - ANSWER-A college student presents to
the health care clinic with reports of no bowel movement for 4 days, bloating, and
generalized abdominal discomfort. She states that she has not been eating and drinking
correctly and is stressed because she has a final exam in 2 days. A nurse assesses the
abdomen and finds positive bowel sounds in all four quadrants and tenderness in the
left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas
sign are negative. What nursing diagnosis can the nurse confirm for this client?
24. body mass index greater than 30
25. taking multiple medications
26. hiatal hernia - ANSWER-A nurse suspects that a client has gastroesophageal reflux
disease (GERD). Which risk factors must be present for the nurse to confirm this? Select
all that apply.
27. Right upper quadrant
Costovertebral angles
Epigastrium - ANSWER-The nurse is admitting a client who is in hypertensive crisis. The
doctor's notes indicate that bruits that are both systolic and diastolic have been noted
and renal artery stenosis is suspected as the cause of the hypertension. Where would
the nurse auscultate the client's abdomen to hear these bruits? (Select all that apply.)
