NR 509 Final Exam with correct
Answers. RATED A+
Appendicitis - answer-1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign
--Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign,
and the psoas sign
--The pain of appendicitis classically begins near the umbilicus, then migrates to
the RLQ. Older adults are less likely to report this pattern.
--Localized tenderness anywhere in the RLQ, even in the right flank, suggests
appendicitis.
McBurney Point - answer-1. McBurney point lies 2 inches from the anterior
superior spinous process of ilium on a line drawn from that process to the
umbilicus
2. Appendicitis is three times more likely if there is McBurney point tenderness.
Rovsing sign - answer-Press deeply and evenly in the LLQ. Then quickly withdraw
your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
,Urge incontinence problem - answer-Detrusor contractions are stronger than
normal and overcome the normal urethral resistance. The bladder is typically
small.
Urge incontinence mechanism - answer-Decreased cortical inhibition of detrusor
contractions from stroke, brain tumor, dementia, and lesions of the spinal cord
above the sacral level.
Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal
impaction.
Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder
volumes.
Urge incontinence symptoms - answer-Involuntary urine loss preceded by an urge
to void. The volume tends to be moderate.
Urgency, frequency, and nocturia with small to moderate volumes. If acute
inflammation is present, pain on urination.
Possibly "pseudo-stress incontinence"—voiding 10-20 sec after stresses such as a
change of position, going up-or downstairs, and possibly coughing, laughing, or
sneezing.
Urge incontinence physical signs - answer-The small bladder is not detectable on
abdominal examination.
When cortical inhibition is decreased, mental deficits or motor signs of central
nervous system disease are often present.
When sensory pathways are hyperexcitable, signs of local pelvic problems or a
fecal impaction may be present.
,Overflow incontinence problem - answer-Detrusor contractions are insufficient to
overcome urethral resistance, causing urinary retention. The bladder is typically
flaccid and large, even after an effort to void.
Overflow incontinence mechanisms - answer-Obstruction of the bladder outlet, as
in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle
associated with peripheral nerve disease at S2-4 level.
Impaired bladder sensation that interrupts the reflex arc, as in diabetic
neuropathy.
Overflow incontinence symptoms - answer-When intravesicular pressure
overcomes urethral resistance, continuous dripping or dribbling incontinence
ensues. Decreased force of the urinary stream.
Prior symptoms of partial urinary obstruction or other symptoms of peripheral
nerve disease may be present.
3. Inspiration: liver is palpable 3cm below right costal margin in midclavicular line.
(gallbladder may merge with liver causing firm oval mass below liver edge)
Percussion tenderness in nonpalpable liver: strike right side with ulnar surface of
hand and compare to sensation felt on left side: tenderness suggests
inflammation (hepatitis or congestion from heart failure).
Spleen assessment - answer-Enlargement: expands anteriorly, downward, and
medially, replacing tympany of stomach and colon with dullness of solid organ.
Percussion:
, 1. Percuss the left lower anterior chest wall roughly from the border of cardiac
dullness at the 6th rib to the anterior axillary line and down to the costal margin,
an area termed Traube space. As you percuss along the route, note the lateral
extent of tympany. Percussion is moderately accurate in detecting splenomegaly
(80% of the time)
2. If tympany is prominent, splenomegaly is unlikely.
3. Check for a splenic percussion sign. Percuss the lowest interspace in the left
anterior axillary line (usually tympanic). Have patient to take a deep breath, and
percuss again. When spleen size is normal, the percussion note usually remains
tympanitic.
Palpation (supine and on right side):
Splenomegaly is eight times more likely when the spleen is palpable (portal
hypertension, hematologic malignancies, HIV infection, infiltrative diseases like
amyloidosis, and splenic infarct or hematoma).
In 5% of normal adults: Spleen tip, is just palpable deep to the left costal margin.
Kidney assessment LEFT - answer-Retroperitoneal and nonpalpable.
Palpation: lay on left side.
Place R hand behind the pt, just below and parallel to the 12th rib, with fingertips
just reaching the CVA. Lift, trying to displace the kidney anteriorly. Place your left
hand gently in the LUQ, lateral and parallel to the rectus muscle. Ask the patient
to take a deep breath. At the peak of inspiration, press your left hand firmly and
deeply into the LUQ, just below the costal margin. Try to "capture" the kidney
between your two hands. Ask the patient to breathe out and then to stop
breathing briefly. Slowly release the pressure of your left hand, feel-ing at the
same time for the kidney to slide back into its expiratory position. If the kidney is
palpable, describe its size, contour, and any tenderness.
OR Deep palpation: Stand on pt right side, use left hand, reach over and around pt
to lift up beneath the left kidney, and with right hand, feel deep in the LUQ. Have
pt to take deep breath, feel for a mass.
Answers. RATED A+
Appendicitis - answer-1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign
--Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign,
and the psoas sign
--The pain of appendicitis classically begins near the umbilicus, then migrates to
the RLQ. Older adults are less likely to report this pattern.
--Localized tenderness anywhere in the RLQ, even in the right flank, suggests
appendicitis.
McBurney Point - answer-1. McBurney point lies 2 inches from the anterior
superior spinous process of ilium on a line drawn from that process to the
umbilicus
2. Appendicitis is three times more likely if there is McBurney point tenderness.
Rovsing sign - answer-Press deeply and evenly in the LLQ. Then quickly withdraw
your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
,Urge incontinence problem - answer-Detrusor contractions are stronger than
normal and overcome the normal urethral resistance. The bladder is typically
small.
Urge incontinence mechanism - answer-Decreased cortical inhibition of detrusor
contractions from stroke, brain tumor, dementia, and lesions of the spinal cord
above the sacral level.
Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal
impaction.
Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder
volumes.
Urge incontinence symptoms - answer-Involuntary urine loss preceded by an urge
to void. The volume tends to be moderate.
Urgency, frequency, and nocturia with small to moderate volumes. If acute
inflammation is present, pain on urination.
Possibly "pseudo-stress incontinence"—voiding 10-20 sec after stresses such as a
change of position, going up-or downstairs, and possibly coughing, laughing, or
sneezing.
Urge incontinence physical signs - answer-The small bladder is not detectable on
abdominal examination.
When cortical inhibition is decreased, mental deficits or motor signs of central
nervous system disease are often present.
When sensory pathways are hyperexcitable, signs of local pelvic problems or a
fecal impaction may be present.
,Overflow incontinence problem - answer-Detrusor contractions are insufficient to
overcome urethral resistance, causing urinary retention. The bladder is typically
flaccid and large, even after an effort to void.
Overflow incontinence mechanisms - answer-Obstruction of the bladder outlet, as
in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle
associated with peripheral nerve disease at S2-4 level.
Impaired bladder sensation that interrupts the reflex arc, as in diabetic
neuropathy.
Overflow incontinence symptoms - answer-When intravesicular pressure
overcomes urethral resistance, continuous dripping or dribbling incontinence
ensues. Decreased force of the urinary stream.
Prior symptoms of partial urinary obstruction or other symptoms of peripheral
nerve disease may be present.
3. Inspiration: liver is palpable 3cm below right costal margin in midclavicular line.
(gallbladder may merge with liver causing firm oval mass below liver edge)
Percussion tenderness in nonpalpable liver: strike right side with ulnar surface of
hand and compare to sensation felt on left side: tenderness suggests
inflammation (hepatitis or congestion from heart failure).
Spleen assessment - answer-Enlargement: expands anteriorly, downward, and
medially, replacing tympany of stomach and colon with dullness of solid organ.
Percussion:
, 1. Percuss the left lower anterior chest wall roughly from the border of cardiac
dullness at the 6th rib to the anterior axillary line and down to the costal margin,
an area termed Traube space. As you percuss along the route, note the lateral
extent of tympany. Percussion is moderately accurate in detecting splenomegaly
(80% of the time)
2. If tympany is prominent, splenomegaly is unlikely.
3. Check for a splenic percussion sign. Percuss the lowest interspace in the left
anterior axillary line (usually tympanic). Have patient to take a deep breath, and
percuss again. When spleen size is normal, the percussion note usually remains
tympanitic.
Palpation (supine and on right side):
Splenomegaly is eight times more likely when the spleen is palpable (portal
hypertension, hematologic malignancies, HIV infection, infiltrative diseases like
amyloidosis, and splenic infarct or hematoma).
In 5% of normal adults: Spleen tip, is just palpable deep to the left costal margin.
Kidney assessment LEFT - answer-Retroperitoneal and nonpalpable.
Palpation: lay on left side.
Place R hand behind the pt, just below and parallel to the 12th rib, with fingertips
just reaching the CVA. Lift, trying to displace the kidney anteriorly. Place your left
hand gently in the LUQ, lateral and parallel to the rectus muscle. Ask the patient
to take a deep breath. At the peak of inspiration, press your left hand firmly and
deeply into the LUQ, just below the costal margin. Try to "capture" the kidney
between your two hands. Ask the patient to breathe out and then to stop
breathing briefly. Slowly release the pressure of your left hand, feel-ing at the
same time for the kidney to slide back into its expiratory position. If the kidney is
palpable, describe its size, contour, and any tenderness.
OR Deep palpation: Stand on pt right side, use left hand, reach over and around pt
to lift up beneath the left kidney, and with right hand, feel deep in the LUQ. Have
pt to take deep breath, feel for a mass.
