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

Correct Answer: Assess the abdomen and notify the provider promptly

Older adults with serious intra-abdominal disease present atypically. Confusion, tachycardia and a falling blood pressure may be the only signs of perforation or ischemic bowel, so the nurse examines the abdomen and escalates without waiting for pain. Option b is incorrect because safety measures treat the confusion as the problem rather than as a symptom. Raising the rails does nothing about the abdominal event that the changing vital signs point toward. Option c is incorrect because sedating a post-operative client who may be developing sepsis masks deterioration and removes the clearest sign the nurse has. New confusion after surgery is investigated, not suppressed. Option d is incorrect because waiting for scheduled rounds allows an abdominal catastrophe to progress in a client whose presentation is already blunted by age. The change in status is itself the reason to act now.

Correct Answer: Pressure on the wall alters peristalsis and sounds

Peristalsis responds to stretch and mechanical deformation, so pressing on the wall stimulates or suppresses bowel activity. A sound heard after percussing or palpating may be one the examiner produced, which makes the finding untrustworthy. Option a is incorrect because comfort is a genuine secondary benefit, not the mechanism. Leading with the stethoscope does relax a client, but the reason the order changes is that touch changes gut motility. Option c is incorrect because sterility has nothing to do with abdominal assessment. The skin surface is not a sterile field, and no step of inspection, auscultation, percussion or palpation depends on maintaining one. Option d is incorrect because percussion quality has no bearing on the ordering rule. Tympany predominates whether or not the bowel has emptied, and percussion is placed third precisely because it disturbs motility more than listening does.

Correct Answer: A pulsatile expansile mass with back pain

A pulsatile expansile mass pushing the fingers apart, especially with back pain, suggests an abdominal aortic aneurysm. The nurse stops palpating and notifies the provider at once, because rupture is catastrophic. Option a is incorrect because mild tenderness over the sigmoid colon during left lower quadrant palpation is a normal expected finding. Tenderness elsewhere in the abdomen is what prompts further investigation. Option b is incorrect because a bulge that slides back through the defect has an intact blood supply and is scheduled for elective repair. Firmness, tenderness or discoloration would change that picture entirely. Option d is incorrect because silvery white striae are old stretch marks from previous weight change or pregnancy. They carry no urgency and belong in routine documentation of the abdominal skin.

Correct Answer: The bowel is failing and the obstruction has worsened

Hyperactive tinkling sounds mean bowel fighting a barrier. When distention compromises the wall and its blood supply, peristalsis fails and the abdomen goes silent. Absent sounds after a hyperactive phase signal deterioration, not recovery. Option b is incorrect because a resolving obstruction announces itself with passage of flatus and stool, easing pain and a softer abdomen. Silence in a distended painful abdomen is the opposite of resolution. Option c is incorrect because bowel rest does not silence an obstructed gut within hours. Loss of all sound points to a wall so stretched and ischemic that it can no longer contract. Option d is incorrect because the nurse listened over every quadrant for a full five minutes, which is the standard required before charting an abdomen as silent. Technique error does not explain this change.

Correct Answer: Report the alarm features for urgent evaluation

Progressive dysphagia, unintentional weight loss and iron deficiency anemia are alarm features in upper gastrointestinal disease. They require urgent evaluation rather than continued symptomatic management, because they can signal malignancy or a bleeding lesion. Option a is incorrect because dietary advice addresses ordinary dyspepsia and does nothing for a client whose swallowing is narrowing and whose blood count is falling. Teaching cannot substitute for diagnostic evaluation here. Option b is incorrect because false reassurance conceals a cluster of findings that specifically argue against a benign fluctuating course. Weight loss and anemia never belong to simple indigestion and must be investigated. Option c is incorrect because a three month interval allows an obstructing or malignant lesion to progress untreated. Alarm features shorten the timeline for endoscopy rather than lengthening it into routine follow-up.

Correct Answer: Keep the client NPO and notify the provider

A tender, discolored, irreducible hernia with vomiting suggests strangulation, where trapped bowel has lost its blood supply. That is a surgical emergency, so the nurse withholds oral intake and notifies the provider at once. Option a is incorrect because forcing a tender, discolored hernia back through the defect may push dead or ischemic bowel into the peritoneal cavity. Reduction is never attempted once these warning features appear. Option c is incorrect because an hour of waiting lets ischemic bowel necrose and perforate. Ice treats neither the obstruction nor the compromised blood supply, and the delay costs the client viable intestine. Option d is incorrect because relaxation and supine positioning help only a reducible hernia slide back on its own. Vomiting with a tense discolored lump signals trapped bowel that needs urgent surgical evaluation.

Correct Answer: Positive obturator sign, suggesting a pelvic appendix

Internal rotation of the flexed right hip stretches the internal obturator muscle. Pain with that movement is a positive obturator sign and suggests an appendix lying in the pelvis or a pelvic abscess. Option a is incorrect because the psoas test moves the leg in a straight line, using resisted hip flexion or passive hip extension. Inward rotation of a bent knee is a different maneuver entirely. Option b is incorrect because Rovsing sign involves no leg movement at all. The examiner palpates deeply in the left lower quadrant, and pain reported in the right lower quadrant is the positive result. Option d is incorrect because Murphy sign is tested at the right costal margin during inspiration and is positive when the client halts the breath. A hip maneuver tells nothing about the gallbladder.

Correct Answer: No tenderness except mild sigmoid tenderness on palpation

The exception has to be written as an exception. Stating no tenderness and then naming a tender area in the same sentence asserts a finding and its negation, so the entry names the sigmoid as the one exception. Option a is incorrect because it converts a normal examination into an abnormal one. The client had tenderness only over the sigmoid colon, and charting generalised tenderness would misrepresent what the student actually found. Option b is incorrect because it drops the sigmoid finding altogether. Mild tenderness over the sigmoid colon is expected rather than meaningless, and the record should show that it was elicited and recognised. Option c is incorrect because tenderness in every quadrant is a different and far more serious picture than tenderness in one. Widening the finding to the whole abdomen invents data the student never obtained.

Correct Answer: One third from the right iliac spine toward the umbilicus

McBurney point lies on a line drawn from the right anterior superior iliac spine to the umbilicus, about one third of the way along that line from the spine. It marks the appendix base. Option a is incorrect because the area between the right costal margin and the iliac crest is the right flank, where kidney and colon lie. Appendiceal tenderness sits lower and closer to the midline. Option c is incorrect because that spot under the right costal margin is where Murphy sign is elicited for gallbladder inflammation. It lies in the right upper quadrant, well above the appendix. Option d is incorrect because periumbilical tenderness reflects the early visceral phase of appendicitis rather than the localized parietal phase. Once pain migrates, maximal tenderness moves to a point in the right lower quadrant.

Correct Answer: Acute cholecystitis remains a real possibility here

Older adults present atypically. Murphy sign is less accurate after age sixty, and a quarter of those clients have no abdominal tenderness at all, so confusion and tachycardia may be the only clues. Option b is incorrect because a negative inspiratory arrest test does not exclude cholecystitis in this age group; the sign loses accuracy after sixty, and many such clients have no tenderness to elicit. Option c is incorrect because new confusion in an older adult is a warning of serious illness, not a finding that a normal white count can explain away. Laboratory values are often unremarkable despite a surgical abdomen. Option d is incorrect because aging blunts the febrile response, so an infected gallbladder or a perforated bowel can be present at a normal temperature. Absent fever lowers no suspicion in this population.

Correct Answer: Tenderness here is expected over the sigmoid

Mild tenderness on palpating the sigmoid colon in the left lower quadrant is a normal finding in the healthy adult. Any other abdominal tenderness is investigated, but this one is expected and needs no follow up. Option a is incorrect because diverticular inflammation brings fever, marked focal pain and altered bowel habit. This client has none of those, so the isolated mild tenderness fits the normal sigmoid rather than an inflammatory process. Option b is incorrect because the ureter lies retroperitoneally and is not palpable through the anterior wall. Ureteral irritation announces itself as colicky flank pain travelling to the groin, together with urinary symptoms. Option d is incorrect because an ovarian mass would feel rounded and discrete rather than firm and tubular. The structure described follows the course of the sigmoid colon, which is where expected tenderness arises.

Correct Answer: Acute pancreatitis from alcohol related injury

Severe constant epigastric pain boring through to the back, eased by leaning forward and worsened by lying flat, is the classic pancreatic pattern, and alcohol is one of the two leading causes of acute pancreatitis. Option a is incorrect because gallbladder pain follows a fatty meal, sits in the right upper quadrant and radiates to the right scapula or shoulder blade, and it is not relieved by leaning forward. Option c is incorrect because free perforation produces sudden generalized pain with a board-like rigid abdomen, and such a client lies absolutely still rather than sitting forward over a table. Option d is incorrect because appendicitis starts as vague periumbilical pain and settles sharply in the right lower quadrant; a retrocecal appendix adds psoas pain, not epigastric pain radiating to the back.

Correct Answer: Hold all oral intake and notify the provider

Loud tinkling sounds that fall silent while pain becomes constant and the pulse rises describe bowel that has stopped working, not bowel that has settled. Strangulation is possible, so intake is stopped and the provider is called. Option b is incorrect because repositioning treats discomfort, not obstruction, and a half-hour delay in this picture allows ischemic bowel to progress toward perforation. The finding already meets the threshold for escalation. Option c is incorrect because fluid and walking are advanced only when bowel function returns, and this abdomen shows the opposite. Giving anything by mouth to an obstructed bowel raises pressure and invites vomiting. Option d is incorrect because silence following a hyperactive phase marks deterioration rather than recovery. Charting it as normal function records a reassuring interpretation of the single most ominous change in an obstructed abdomen.

Correct Answer: Cullen sign indicating intra-abdominal bleeding

Cullen sign is bluish periumbilical ecchymosis produced when blood tracks along fascial planes to the subcutaneous tissue around the navel. With severe epigastric pain it suggests hemorrhagic pancreatitis and demands immediate escalation. Option a is incorrect because Grey Turner sign is ecchymosis of the flanks, where blood has tracked laterally through the retroperitoneum. Remember that Turner has two flanks while Cullen circles the umbilicus. Option b is incorrect because caput medusae describes dilated veins radiating outward from the navel, not bruised skin. Those collaterals form when portal hypertension forces blood through recanalized umbilical channels in liver disease. Option c is incorrect because a Sister Mary Joseph nodule is a hard lump felt in the umbilicus, signaling metastatic intra-abdominal cancer. The finding described is a color change, with no mass present.

Correct Answer: Listen a full five minutes by the watch

Silent abdomen is uncommon, and the standard is to listen five minutes by the watch before deciding that bowel sounds are completely absent. One minute is too short to support that word in the record. Option a is incorrect because the finding has not yet been confirmed. Charting absence prematurely can trigger an unnecessary workup or change feeding decisions, and the word carries weight precisely because it is rarely true. Option c is incorrect because no source requires four separate timed periods of listening. The published requirement is one sustained period, and twenty minutes of auscultation would be an unreasonable reading of the rule. Option d is incorrect because pressing hard is mechanical stimulation that provokes peristalsis. Any sound produced that way is created by the examiner, which defeats the purpose of determining whether motility has genuinely stopped.

Correct Answer: Percuss the liver span at the midclavicular line

Span settles what edge position cannot. A hyperinflated chest depresses the diaphragm and pushes a normal liver downward, so the nurse percusses both borders along the right midclavicular line and measures between them. Option a is incorrect because feeling the same edge a second time repeats information already obtained and still measures only one border. The size of the organ cannot be judged from its lower edge alone. Option b is incorrect because girth measurement tracks distention and fluid accumulation over time rather than the size of a single organ. Nothing in this assessment suggests that the abdomen is enlarging. Option d is incorrect because jaundice points to bile handling and is not what separates a displaced liver from an enlarged one. The client reports no pain and no other sign of liver disease.

Correct Answer: Perform a bedside bladder scan on the client

Dullness above the symphysis with an urge to void points to a full bladder. Bedside ultrasound, not percussion, is how bladder volume is measured, and the scan gives a number the nurse can act on. Option a is incorrect because harder percussion over a distended bladder is uncomfortable and still yields only an impression of density. Repeating an unreliable technique does not turn it into a measurement. Option b is incorrect because deep pressure on a full bladder causes pain and may provoke leakage, and the suspected structure has already been identified. A bladder rising out of the pelvis is not a mass. Option c is incorrect because a distended bladder explains the note entirely, and the client has just described the symptom that fits it. Charting an abnormality first would record a conclusion the nurse has not yet tested.

Correct Answer: Rovsing sign, consistent with acute appendicitis

Rovsing sign is deep pressure in the left lower quadrant that produces pain in the right lower quadrant. Displaced gas and peritoneal stretch transmit to the inflamed appendix, so it points specifically to appendicitis. Option b is incorrect because Blumberg sign is rebound tenderness, elicited by pushing down slowly and then lifting the hand quickly. Pain must appear on release, not during sustained pressure on the opposite quadrant. Option c is incorrect because the obturator test requires flexing the right thigh at the hip with the knee bent and then rotating the leg internally. No rotation of the leg took place. Option d is incorrect because a psoas test is performed by raising the straightened right leg against downward resistance, or by extending the hip with the client side-lying. Neither maneuver involves palpating another quadrant.

Correct Answer: Measuring and recording vital signs every hour

Taking and recording vital signs on a stable client is within the scope of unlicensed assistive personnel. Assessment maneuvers, teaching, and comfort measures that could harm an inflamed appendix stay with the nurse. Option a is incorrect because eliciting rebound tenderness is an assessment skill requiring nursing judgment, and it causes severe pain and muscle rigidity. The nurse performs it once, last, and never delegates it. Option b is incorrect because heat is never applied to an undiagnosed acute abdomen. Warmth increases local blood flow and inflammation and can help push an inflamed appendix toward rupture, so no one should do this. Option c is incorrect because client and family teaching is a licensed nursing responsibility that cannot be handed to assistive personnel. Explaining why laxatives raise perforation risk requires clinical knowledge the role does not include.

Correct Answer: Have you had mucus or urgency with these stools?

Frank red blood passed per rectum is hematochezia, which localizes bleeding to the lower tract or anorectum. Asking about mucus and urgency separates colonic inflammation from a painless diverticular bleed or hemorrhoids. Option a is incorrect because iron turns stool black and non-tarry rather than bright red, so the question addresses a finding this client does not have and moves the history away from the lower tract. Option c is incorrect because hematemesis belongs to an upper source, and blood from the stomach arrives at the rectum digested and black. Bright red blood has already told the nurse the source is low. Option d is incorrect because fatty meals provoke gallbladder pain in the right upper quadrant and have nothing to do with rectal bleeding. The question gathers no information that narrows this presentation.