NR509 Final Exam Study Guide | Advanced Physical
Assessment Questions &Answers & Review |Well
Rationalized and Revised |Frequently Most Tested
Questions and 100% Accurate | High Yield Questions
and Answers | Newest Exam and Latest Version!!!
CHAPTER 19: Abdomen
A 76-year-old retired man with a history of prostate cancer and hypertension
has been screened annually for colon cancer using high sensitivity fecal occult
blood testing (FOBT). He presents for follow-up of his hypertension, during
which the clinician scans his chart to ensure he is up to date with his preventive
health care. He has a positive FOBT on one occasion at age 66 years and
subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid
diverticuli were found on colonoscopy. He has no first-degree relatives with a
history of colorectal cancer or adenomatous polyps. What are the U.S.
Preventive Services Task Force (USPSTF) screening recommendations for this
patient?
ANSWER:<<Do not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults
ages 76-85 years, the gain in life years is small compared to colonoscopy risks.
It is advised to discuss individualized risks and benefits with the patient. Annual
FOBT screening may continue until age 80-85 years if benefits to doing so
outweigh risks for the individual patient; however, screening should not be
routinely continued. In general, a life expectancy >7 years is necessary for
screening to be potentially beneficial. There is no indication to repeat a
colonoscopy given the absence of any cancerous or precancerous findings on
his colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3
years is a valid screening option, but again screening is not routinely
recommended for patients age >75 years.
CHAPTER 19: Abdomen
An overweight 26-year-old public servant presents to the Emergency
Department with 12 hours of intense abdominal pain, light-headedness, and a
fainting episode that finally prompted her to seek medical attention. She has a
,strong family history of gallstones and is concerned about this possibility. She
has not had any vomiting or diarrhea. She had a normal bowel movement this
morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She
reports that her last periterm-12od was 10 weeks ago. Her vital signs at triage
are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen
saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an
abdominal exam prior to her pelvic exam and, on palpation of her abdomen,
finds involuntary rigidity and rebound tenderness. What is the most likely
diagnosis?
ANSWER:<<Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia,
hypotension, positive β-hCG, and findings suggestive of peritoneal
inflammation/irritation strongly suggest a ruptured ectopic pregnancy with
significant intra-abdominal bleeding leading to peritoneal signs. This case is
emergent and requires immediate treatment of her hypotension and presumed
blood loss as well as gynecological consult for emergent surgery. Ruptured
ectopic pregnancies can lead to life-threatening intra-abdominal bleeding.
Although acute cholecystitis, ruptured appendix, bowel wall perforation, and
ruptured ovarian cyst are all possibilities, the positive β-hCG testing and her
unstable vital signs make ruptured ectopic pregnancy more likely.
CHAPTER 19: Abdomen
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a
well visit. Basic labs are performed to screen for diabetes mellitus and
dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are
all normal expect for moderate elevations of aspartate aminotransferase,
alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as
well as a mildly elevated total bilirubin. He presents for a follow-up appointment
and the clinician performs an abdominal exam to assess his liver. Which of the
following findings would be most consistent with hepatomegaly?
ANSWER:<<Liver palpable 3 cm below the right costal margin, mid clavicular
line, on expiration
Rationale: The liver being palpable 3 cm below the right costal margin,
midclavicular line, would be considered normal on inspiration when the liver is
pushed down into the abdominal cavity on inspiration, but is abnormal on
expiration. Findings to support hepatomegaly would be more convincing if, by
percussion, the liver span was >12 cm at the midclavicular line. For patients with
,obstructive lung disease, air trapping in the lungs may displace the liver
downwards into the abdominal cavity. The liver span and dullness to percussion
refer to the same measurement. Measurements of 6-12 cm at the mid-clavicular
line and 4-8 cm at the midsternal line are considered normal.
CHAPTER 19: Abdomen
A 63-year-old underweight administrative clerk with a 50-pack-year smoking
history presents with a several month history of recurrent epigastric abdominal
discomfort. She feels fairly well otherwise and denies any nausea, vomiting,
diarrhea, or constipation. She reports that a first cousin died from a ruptured
aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92;
respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body
mass index is 17.6. On exam, her abdominal aorta is prominent, which is
concerning for an abdominal aortic aneurysm (AAA). Which of the following is
her most significant risk factor for an AAA?
ANSWER:<<History of smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male
gender, not female gender, is considered as risk factor. Underweight is not a
risk factor for AAA. Family history of ruptured aneurysm is vague and could be a
cerebral aneurysm. Further, her family history is in a first-degree cousin not a
first-degree relative (biologic parents, siblings, and children). Hypertension
could contribute to atherosclerosis, which is a risk factor. Further, a diagnosis
of hypertension is not based on one elevated blood pressure reading.
CHAPTER 19: Abdomen
An otherwise healthy 31-year-old accountant presents to an outpatient clinic
with a 3-year history of recurrent crampy abdominal pain that lasts for about 1-2
weeks each episode and is associated with onset of constipation. She describes
infrequent, small hard stool that she finds very difficult to pass. She has tried to
increase dietary fiber and water intake, but usually this is not sufficient and she
resorts to over-the-counter laxatives, which she finds upset her stomach but do
resolve the constipation. Symptoms typically gradually resolve with bowel
movements. Which of the following is the most likely physiological mechanism
for her constipation?
ANSWER:<<Functional change in bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable
bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea
predominant, constipation predominant, or mixed. Other functional causes for
, her constipation should be excluded prior to making this diagnosis. A large firm
fecal mass in the rectum is characteristic of fecal impaction, which is common in
debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a
diet low in fiber. This patient had not found that increasing fiber helps her
constipation. Spasm of the external sphincter is associated with painful anal
lesions, which this patient does not report. Impairment of autonomic
innervations is characteristic of patients with multiple sclerosis, spinal cord
injuries, and Hirschsprung disease. She has no known diagnosis that would
increase suspicion of neurological impairment.
CHAPTER 19: Abdomen
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic
sinusitis and bronchiectasis that is associated with a rare congenital condition
called Kartagener syndrome. The preceptor notes that she has situs inversus
and asks for a physical exam. Which of the following descriptions best fits with
findings on the abdominal exam?
ANSWER:<<Tympany to percussion in the right upper quadrant, dullness to
percussion of the left upper quadrant
Rationale: Situs inversus is a rare condition in which organs are reversed and is
associated with Kartagener syndrome. Thus, the stomach and gastric air bubble
are on the right and liver dullness is on the left. A protuberant abdomen with
scattered areas of dullness and tympany and stool on palpation is likely
constipation. None of these findings suggest organ reversal. Liver dullness will
occur in the left upper quadrant with organ reversal. Findings given in the
remaining answer choices are both associated with splenomegaly with the
spleen located in the left upper quadrant, which would not be the case for sinus
inversus totalis.
CHAPTER 19: Abdomen
An otherwise healthy 28-year-old lawyer presents to the Emergency Department
with a 1-day history of severe abdominal pain. The emergency physician
suspects appendicitis and general surgery is consulted. The resident believes
the patient has signs of peritonitis on exam. Which of the following physical
exam findings supports peritonitis?
ANSWER:<<Pressing down onto the abdomen firmly and slowly and withdrawing
the hand quickly produces pain
Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing
the hand quickly producing pain describes rebound tenderness, which, along
Assessment Questions &Answers & Review |Well
Rationalized and Revised |Frequently Most Tested
Questions and 100% Accurate | High Yield Questions
and Answers | Newest Exam and Latest Version!!!
CHAPTER 19: Abdomen
A 76-year-old retired man with a history of prostate cancer and hypertension
has been screened annually for colon cancer using high sensitivity fecal occult
blood testing (FOBT). He presents for follow-up of his hypertension, during
which the clinician scans his chart to ensure he is up to date with his preventive
health care. He has a positive FOBT on one occasion at age 66 years and
subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid
diverticuli were found on colonoscopy. He has no first-degree relatives with a
history of colorectal cancer or adenomatous polyps. What are the U.S.
Preventive Services Task Force (USPSTF) screening recommendations for this
patient?
ANSWER:<<Do not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults
ages 76-85 years, the gain in life years is small compared to colonoscopy risks.
It is advised to discuss individualized risks and benefits with the patient. Annual
FOBT screening may continue until age 80-85 years if benefits to doing so
outweigh risks for the individual patient; however, screening should not be
routinely continued. In general, a life expectancy >7 years is necessary for
screening to be potentially beneficial. There is no indication to repeat a
colonoscopy given the absence of any cancerous or precancerous findings on
his colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3
years is a valid screening option, but again screening is not routinely
recommended for patients age >75 years.
CHAPTER 19: Abdomen
An overweight 26-year-old public servant presents to the Emergency
Department with 12 hours of intense abdominal pain, light-headedness, and a
fainting episode that finally prompted her to seek medical attention. She has a
,strong family history of gallstones and is concerned about this possibility. She
has not had any vomiting or diarrhea. She had a normal bowel movement this
morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She
reports that her last periterm-12od was 10 weeks ago. Her vital signs at triage
are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen
saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an
abdominal exam prior to her pelvic exam and, on palpation of her abdomen,
finds involuntary rigidity and rebound tenderness. What is the most likely
diagnosis?
ANSWER:<<Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia,
hypotension, positive β-hCG, and findings suggestive of peritoneal
inflammation/irritation strongly suggest a ruptured ectopic pregnancy with
significant intra-abdominal bleeding leading to peritoneal signs. This case is
emergent and requires immediate treatment of her hypotension and presumed
blood loss as well as gynecological consult for emergent surgery. Ruptured
ectopic pregnancies can lead to life-threatening intra-abdominal bleeding.
Although acute cholecystitis, ruptured appendix, bowel wall perforation, and
ruptured ovarian cyst are all possibilities, the positive β-hCG testing and her
unstable vital signs make ruptured ectopic pregnancy more likely.
CHAPTER 19: Abdomen
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a
well visit. Basic labs are performed to screen for diabetes mellitus and
dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are
all normal expect for moderate elevations of aspartate aminotransferase,
alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as
well as a mildly elevated total bilirubin. He presents for a follow-up appointment
and the clinician performs an abdominal exam to assess his liver. Which of the
following findings would be most consistent with hepatomegaly?
ANSWER:<<Liver palpable 3 cm below the right costal margin, mid clavicular
line, on expiration
Rationale: The liver being palpable 3 cm below the right costal margin,
midclavicular line, would be considered normal on inspiration when the liver is
pushed down into the abdominal cavity on inspiration, but is abnormal on
expiration. Findings to support hepatomegaly would be more convincing if, by
percussion, the liver span was >12 cm at the midclavicular line. For patients with
,obstructive lung disease, air trapping in the lungs may displace the liver
downwards into the abdominal cavity. The liver span and dullness to percussion
refer to the same measurement. Measurements of 6-12 cm at the mid-clavicular
line and 4-8 cm at the midsternal line are considered normal.
CHAPTER 19: Abdomen
A 63-year-old underweight administrative clerk with a 50-pack-year smoking
history presents with a several month history of recurrent epigastric abdominal
discomfort. She feels fairly well otherwise and denies any nausea, vomiting,
diarrhea, or constipation. She reports that a first cousin died from a ruptured
aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92;
respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body
mass index is 17.6. On exam, her abdominal aorta is prominent, which is
concerning for an abdominal aortic aneurysm (AAA). Which of the following is
her most significant risk factor for an AAA?
ANSWER:<<History of smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male
gender, not female gender, is considered as risk factor. Underweight is not a
risk factor for AAA. Family history of ruptured aneurysm is vague and could be a
cerebral aneurysm. Further, her family history is in a first-degree cousin not a
first-degree relative (biologic parents, siblings, and children). Hypertension
could contribute to atherosclerosis, which is a risk factor. Further, a diagnosis
of hypertension is not based on one elevated blood pressure reading.
CHAPTER 19: Abdomen
An otherwise healthy 31-year-old accountant presents to an outpatient clinic
with a 3-year history of recurrent crampy abdominal pain that lasts for about 1-2
weeks each episode and is associated with onset of constipation. She describes
infrequent, small hard stool that she finds very difficult to pass. She has tried to
increase dietary fiber and water intake, but usually this is not sufficient and she
resorts to over-the-counter laxatives, which she finds upset her stomach but do
resolve the constipation. Symptoms typically gradually resolve with bowel
movements. Which of the following is the most likely physiological mechanism
for her constipation?
ANSWER:<<Functional change in bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable
bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea
predominant, constipation predominant, or mixed. Other functional causes for
, her constipation should be excluded prior to making this diagnosis. A large firm
fecal mass in the rectum is characteristic of fecal impaction, which is common in
debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a
diet low in fiber. This patient had not found that increasing fiber helps her
constipation. Spasm of the external sphincter is associated with painful anal
lesions, which this patient does not report. Impairment of autonomic
innervations is characteristic of patients with multiple sclerosis, spinal cord
injuries, and Hirschsprung disease. She has no known diagnosis that would
increase suspicion of neurological impairment.
CHAPTER 19: Abdomen
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic
sinusitis and bronchiectasis that is associated with a rare congenital condition
called Kartagener syndrome. The preceptor notes that she has situs inversus
and asks for a physical exam. Which of the following descriptions best fits with
findings on the abdominal exam?
ANSWER:<<Tympany to percussion in the right upper quadrant, dullness to
percussion of the left upper quadrant
Rationale: Situs inversus is a rare condition in which organs are reversed and is
associated with Kartagener syndrome. Thus, the stomach and gastric air bubble
are on the right and liver dullness is on the left. A protuberant abdomen with
scattered areas of dullness and tympany and stool on palpation is likely
constipation. None of these findings suggest organ reversal. Liver dullness will
occur in the left upper quadrant with organ reversal. Findings given in the
remaining answer choices are both associated with splenomegaly with the
spleen located in the left upper quadrant, which would not be the case for sinus
inversus totalis.
CHAPTER 19: Abdomen
An otherwise healthy 28-year-old lawyer presents to the Emergency Department
with a 1-day history of severe abdominal pain. The emergency physician
suspects appendicitis and general surgery is consulted. The resident believes
the patient has signs of peritonitis on exam. Which of the following physical
exam findings supports peritonitis?
ANSWER:<<Pressing down onto the abdomen firmly and slowly and withdrawing
the hand quickly produces pain
Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing
the hand quickly producing pain describes rebound tenderness, which, along
