NR-304 Health Assessment II - Set 2 - Part 1

Correct Answer: Traube space tympanitic, spleen not percussible

A normal spleen is dull where it lies, so charting absent splenic dullness inverts the finding. What is normally tympanitic is Traube space, and a normal spleen cannot be percussed below the left costal margin. Option a is incorrect because it denies the dullness that a normal spleen actually produces in that quadrant. The entry reads as though a normal organ were missing rather than lying where it belongs. Option b is incorrect because it repeats the same inversion in different words. Splenic dullness is expected over the organ, and what the nurse should negate is enlargement extending below the costal margin. Option d is incorrect because a normal spleen is hidden behind rib and gastric gas and is not readily percussed. Dullness that is easy to find in that area suggests splenomegaly, which this client does not have.

Correct Answer: The first has a duodenal ulcer, the second gastric

Duodenal ulcer pain comes two to three hours after eating and at night and is relieved by food, which buffers acid. Gastric ulcer pain is not relieved by food and is often provoked by it. Option b is incorrect because it reverses the food relationship. Relief with eating and nocturnal pain belong to the duodenal ulcer, while pain that eating makes worse belongs to the gastric ulcer. Option c is incorrect because only the first description fits a duodenal lesion. Burning that worsens when food arrives in the stomach points away from the duodenum and toward a gastric mucosal break. Option d is incorrect because reflux disease produces retrosternal burning and regurgitation tied to recumbency and bending, not a reproducible relationship between the epigastric ache and the timing of a meal.

Correct Answer: Sour regurgitation of gastric contents into the throat

Reflux of acid into the unprotected esophageal mucosa produces pyrosis after meals and when recumbent, and regurgitation of sour or bitter gastric contents into the throat is the second classic symptom of GERD. Option a is incorrect because bloody diarrhea with mucus and urgency is the hallmark of ulcerative colitis, where inflammation is confined to the friable colonic mucosa; acid injures the esophagus here, not the large bowel. Option b is incorrect because black tarry stool is melena, the sign of digested blood from an upper gastrointestinal bleed such as an ulcer; uncomplicated reflux disease does not produce blood loss. Option d is incorrect because rebound tenderness signals peritoneal inflammation, and it points toward appendicitis rather than reflux; the abdominal examination in this condition is typically normal or shows only mild epigastric tenderness.

Correct Answer: Notify the provider and keep the client NPO

Constant pain with fever, tachycardia, rebound tenderness and guarding signals strangulation, meaning bowel is ischemic or perforating. This is a surgical emergency, so the nurse escalates immediately and keeps the client with nothing by mouth. Option a is incorrect because walking does nothing for a mechanical blockage and delays the surgical evaluation this client needs. Peritoneal signs mean the problem has moved well beyond trapped gas. Option b is incorrect because comfort measures alone leave ischemic bowel untreated while sepsis develops. Applying warmth over an acutely inflamed abdomen is also avoided, since it increases blood flow and speeds the inflammation. Option c is incorrect because laxatives raise pressure inside an obstructed bowel and can precipitate perforation. Nothing goes by mouth once an acute surgical abdomen is suspected, whether or not an order exists.

Correct Answer: Free fluid within the peritoneal cavity

Bulging flanks, taut shiny skin, an everted umbilicus and dependent leg edema in liver disease point to ascites. Portal hypertension and low albumin drive fluid into the peritoneal cavity and into the legs. Option a is incorrect because gaseous distention gives tympany or frank hyperresonance over the flanks as well as the midline, and it does not evert the umbilicus or produce leg swelling. Option b is incorrect because a stool-loaded colon is felt as firm movable masses along its course, with dullness only over those segments. Retained feces explains neither shiny stretched skin nor bilateral leg edema. Option d is incorrect because obesity sinks the umbilicus deeply rather than pushing it outward, and the abdomen stays soft and uniformly rounded. Adipose tissue also does not pool in the flanks under gravity.

Correct Answer: Removing the colon removes all ulcerative colitis

Ulcerative colitis is confined to the colon and begins at the rectum, so removing the colon removes every site the disease can occupy. Crohn disease can recur anywhere from mouth to anus after resection. Option b is incorrect because Crohn disease is not limited to the terminal ileum. Its skip lesions may appear at any point between the mouth and the anus, so resecting one segment leaves disease behind. Option c is incorrect because surgery is not futile in either condition, and for the client whose inflammation stops at the colon it eliminates the entire diseased organ rather than only relieving symptoms. Option d is incorrect because a colectomy cannot cure transmural disease that also involves the small bowel, the mouth and the perianal area; only the colon-limited condition is eradicated by that operation.

Correct Answer: Visible peristalsis indicating intestinal obstruction

Marked visible peristalsis combined with a distended abdomen indicates intestinal obstruction. Bowel proximal to the blockage contracts harder and harder against it, and in a thin wall those hypertrophied contractions become visible from outside. Option a is incorrect because peristaltic waves are a benign incidental finding only when the abdomen is otherwise normal. Here they accompany distention, vomiting and absent stool, a combination that shifts the finding from variant to warning. Option b is incorrect because aortic pulsation appears in the epigastrium as a rhythmic lift timed with the heartbeat. It does not travel across the abdomen as a slow oblique wave, and it does not accompany obstruction. Option c is incorrect because respiratory movement raises and lowers the whole wall in time with breathing, most noticeably in men. Nothing about that gentle rise resembles waves crossing the surface in one direction.

Correct Answer: Bowel sounds active in all four quadrants

Active in all four quadrants is the phrasing the course models for a normal abdomen. It uses the course vocabulary of active, normoactive, hypoactive and absent, and it states the finding as a single complete entry. Option b is incorrect because normal active is not a term this course uses, and splitting the entry leaves a sentence fragment. Charting should name the sounds as active or normoactive in all four quadrants. Option c is incorrect because no authoritative source sets forty-five sounds per minute as any kind of threshold. The normal range is five to thirty per minute, and character rather than rate is what gets documented. Option d is incorrect because the course instructs the examiner not to bother counting bowel sounds. Timed counting belongs only to the five minutes of listening required before an abdomen may be called silent.

Correct Answer: Diverticulosis bleeding without inflammation

Diverticulosis is the presence of outpouchings without inflammation. It is typically asymptomatic and is a common cause of painless lower gastrointestinal bleeding when a vessel at the neck of a diverticulum erodes. Option a is incorrect because diverticulitis means a diverticulum has become inflamed and micro-perforated, which brings left lower quadrant pain, fever, leukocytosis and tenderness over the segment. None of those findings is present here. Option b is incorrect because blood from the stomach or duodenum is digested during transit and emerges as black tarry melena, not as the large volume of frank red blood this client passed. Option c is incorrect because a colitis flare brings bloody diarrhea mixed with mucus, urgency and left lower quadrant cramping rather than a single painless hemorrhage from an otherwise quiet colon.

Correct Answer: Peritonitis from inflammation of the parietal peritoneum

Parietal peritoneal pain is sharp and worsened by any stretch of the inflamed surface, so the client lies absolutely still. Colicky visceral pain does the opposite, leaving the client restless and unable to settle. Option a is incorrect because a client passing a ureteral stone typically writhes and cannot find any comfortable position. Flank pain radiating to the groin, not motionless guarding of the abdomen, marks renal colic. Option b is incorrect because biliary colic produces building right upper quadrant pain that comes and goes as the stone shifts, and the client tends to move about restlessly rather than freeze in place. Option d is incorrect because viral gastroenteritis causes crampy midline discomfort with vomiting and diarrhea, and clients shift position freely. Absolute stillness with drawn-up knees points to somatic pain from an inflamed peritoneum.

Correct Answer: The right lower pole is normally palpable here

The lower pole of the right kidney is occasionally felt in a normal adult as a smooth round mass sliding between the hands. The left kidney sits about a centimetre higher and is normally not palpable. Option a is incorrect because nothing in this examination suggests enlargement. Feeling the right lower pole is an expected variant in a thin person, and the left side produced no finding at all. Option b is incorrect because a dropped kidney is not what this finding describes. The liver sits above the right kidney and holds it lower than the left, which is why only that pole is reachable. Option c is incorrect because failure to feel the left kidney is the expected result of the maneuver. Its higher position under the ribs keeps it out of reach in virtually every healthy adult.

Correct Answer: Omit the test and report the findings

Rigidity with tenderness on light touch has already established peritoneal irritation. Pressing deeply and releasing would add no information while causing severe pain and more rigidity, so the nurse leaves the abdomen alone and reports. Option b is incorrect because performing the test even once inflicts severe pain for a conclusion already reached. The rule is to test at the end of an examination, and not at all when rigidity is obvious. Option c is incorrect because moving to another quadrant does not make deep pressure safe in an abdomen that is rigid throughout. Choosing a site away from the pain matters only when the test is indicated. Option d is incorrect because waiting assumes the pain will settle, and peritoneal inflammation does not settle on its own. The finding needs a surgeon now rather than a later attempt at a painful maneuver.

Correct Answer: The marks suggest excess adrenocortical hormone

Striae begin pink or blue and fade to silvery white, so colour dates them. Purple blue striae occur with Cushing syndrome, where excess adrenocortical hormone weakens the skin so it tears under ordinary stretch. Option a is incorrect because striae left over from pregnancy have long since turned silvery white. The colour described is fresh, and pairing it with central obesity and facial rounding points to a hormonal cause. Option c is incorrect because collateral veins radiate outward from the umbilicus as a branching pattern known as caput medusae. They accompany portal hypertension and cirrhosis, and they are vessels rather than linear tears in the dermis. Option d is incorrect because bruises are irregular blotches that change through green and yellow as they resolve. The finding described is linear, distributed across an area of stretch, and accompanied by other cushingoid features.

Correct Answer: Umbilicus midline and inverted without inflammation

A normal umbilicus sits in the midline and is inverted, with no discoloration, inflammation or herniation. The course charts negative findings rather than leaving them out, so the entry names what was inspected and found normal. Option a is incorrect because an everted umbilicus is pushed out by raised pressure inside the abdomen, as happens with ascites or an underlying mass. It is an abnormal finding requiring further assessment. Option b is incorrect because tympany, not dullness, predominates in the supine abdomen as intestinal gas rises against the anterior wall. Widespread dullness suggests fluid, a mass or a full bladder. Option d is incorrect because a scaphoid abdomen is sunken and caved in, which is seen with malnutrition and severe weight loss. Normal adult contour ranges only from flat to rounded.

Correct Answer: Report the findings, since cholecystitis is not excluded

Murphy sign is less accurate after age sixty, and about a quarter of those clients have no abdominal tenderness at all. Fever with new confusion may be the only sign of serious intra-abdominal disease. Option b is incorrect because a negative Murphy result does not rule out gallbladder inflammation in an older adult. Charting the assessment as normal and waiting allows an evolving infection to progress unrecognized. Option c is incorrect because repeating the maneuver yields no new information and causes needless pain over an inflamed organ. Diagnosis depends on ultrasound imaging, laboratory results and the whole clinical picture instead. Option d is incorrect because confusion is never explained by age alone. In older adults a sudden change in mental status, tachycardia or low blood pressure can be the only clue to a surgical abdomen.

Correct Answer: Stop palpating and report the finding promptly

An enlarged spleen ruptures easily, so the first action is to stop palpating and refer the finding. Splenomegaly accompanies mononucleosis, and repeated pressure on a friable organ risks a rupture that the examination itself would cause. Option a is incorrect because a second pass adds nothing and multiplies the hazard. A spleen must enlarge to roughly three times normal size before it can be felt, so feeling one at all settles the question. Option b is incorrect because measuring by repeated deep pressure is the most dangerous response available. Size is recorded once, in centimetres below the left costal margin, and imaging rather than the hand establishes the true dimension. Option c is incorrect because delay leaves a rupture risk unreported while the examination continues. This finding is one of the explicit safety imperatives in abdominal assessment, and it outranks completing the remaining quadrants.

Correct Answer: "Are you taking an iron supplement each day?"

Black stool has two common explanations that must be separated. Tarry black stool is melena from digested upper gastrointestinal blood, while non-tarry black stool comes from oral iron, so the nurse asks about iron first. Option a is incorrect because fever does not distinguish digested blood from a harmless medication effect. It is worth knowing eventually, but it does not address the finding the client actually reported. Option b is incorrect because family history shapes screening decisions rather than explaining today's stool colour. The immediate task is to find out whether this stool represents bleeding at all. Option d is incorrect because appetite change is a broad symptom that fits many conditions and none in particular. It cannot separate the two causes of black stool that the nurse must rule between.

Correct Answer: Acute appendicitis with peritoneal involvement

Anorexia, then vague periumbilical visceral pain, then migration to a sharply localized right lower quadrant pain made worse by coughing, is the appendicitis sequence produced when inflammation reaches the overlying parietal peritoneum. Option a is incorrect because diverticular inflammation sits in the left lower quadrant where the sigmoid lies, usually in an older adult, and it does not begin as pain around the umbilicus that later migrates. Option c is incorrect because ulcerative colitis produces weeks of bloody diarrhea with mucus and urgency, not a single day of pain that shifts from the midline and then fixes at one point. Option d is incorrect because biliary colic causes building epigastric or right upper quadrant pain after a fatty meal that settles within hours, and it carries no localized tenderness low on the right.

Correct Answer: The right lower quadrant, at the ileocecal valve

Auscultation begins in the right lower quadrant at the ileocecal valve because bowel sounds are normally always present there. From that busy transit point the nurse moves clockwise to the right upper, left upper and left lower quadrants. Option a is incorrect because the sigmoid colon carries formed stool and moves far less often than the small bowel. Silence there tells the nurse little, whereas silence at the ileocecal valve is genuinely informative. Option b is incorrect because the epigastrium is a vascular listening site rather than the starting point for bowel sounds. The aorta is auscultated there, and the celiac bruit variant is heard between xiphoid and umbilicus. Option d is incorrect because beginning on the left reverses the clockwise route the examination follows. The left upper quadrant is the third site visited, and starting there offers no guarantee that sound will be present.

Correct Answer: Record how much fluid each resident drinks

Measuring and recording oral intake is a standardized task with a predictable outcome, so it falls within the assistive role. Interpreting findings, assessing an abdomen and deciding on treatment all require nursing judgment. Option a is incorrect because deciding what black stool means requires separating melena from the harmless darkening caused by oral iron. That analysis belongs to the nurse, not to an assistant. Option b is incorrect because examining an abdomen for tenderness and guarding is a skilled assessment that requires interpretation of what the hands find. Delegating it would put an untrained person in a judgment role. Option c is incorrect because choosing a laxative is a treatment decision that carries real risk in a resident whose bowel may be obstructed or inflamed. Assistants do not make that judgment.