When assessing for borborygmi which physical examination method should the nurse use

1 / 1 pts

Which structure is located in the left lower quadrant of the abdomen?

Liver Duodenum Gallbladder Sigmoid colon

Question 2

1 / 1 pts

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of the following is true regarding assessment of the spleen in this situation?

The spleen can be palpated under the right costal margin. The spleen is normally felt upon routine palpation. If an enlarged spleen is noted, palpate thoroughly to determine size. An enlarged spleen should not be palpated because it can rupture easily.

Question 3

1 / 1 pts

While examining a patient, the nurse observes a barely visible abdominal pulsation between the xiphoid and umbilicus. The nurse would suspect that these are:

pulsations of the renal arteries. pulsations of the inferior vena cava. normal abdominal aortic pulsations. increased peristalsis from a bowel obstruction.

Question 4

1 / 1 pts

The main reason auscultation precedes percussion and palpation of the abdomen is to:

allow the patient more time to relax and therefore be more comfortable with the physical examination. determine areas of tenderness before using percussion and palpation. prevent distortion of bowel sounds that might occur after percussion and palpation. prevent distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation.

Question 5

1 / 1 pts

The physician comments that a patient has abdominal “borborygmi.” The nurse knows that this term refers to:

a loud continuous hum. a peritoneal friction rub. hypoactive bowel sounds. hyperactive bowel sounds.

Question 6

1 / 1 pts

Which of the following is a normal finding in the abdominal assessment?

The presence of a bruit in the femoral area A tympanic percussion note in all four quadrants of the abdomen A palpable spleen between the ninth and eleventh ribs in the left midaxillary line A dull percussion note in the left lower quadrant at the midclavicular line

Question 7

1 / 1 pts

A nurse notes that a patient has ascites, which indicates that which of the following is present?

Feces Flatus Fluid Fibroid tumors

Question 8

1 / 1 pts

Tenderness on light palpation in the right lower quadrant could indicate a disorder of which of the following structures?

Spleen Sigmoid Appendix Gallbladder

Question 9

1 / 1 pts

Before reporting this finding as “silent bowel sounds” the nurse should listen for at least:

1 minute. 10 minutes. 25 minutes in each quadrant. 5 minutes.

Question 10

1 / 1 pts

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and move his feet apart. The nurse would document this finding as a(n)

ataxia lack of coordination negative Homan's sign positive Romberg's sign

Question 15

1 / 1 pts

The nurse is performing a neurological assessment on 41-year-old women with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notes the following: unable to feel vibrations on the great toe or ankle bilaterally; is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

Hyperalgesia Peripheral neuropathy Low back pain Lesion of sensory cortex

Question 16

1 / 1 pts

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

Extinction Astereognosis Graphesthesia Tactile discrimination

Question 17

1 / 1 pts

During the assessment of an 80-year-old patient, the nurse notes that his hands show slight tremors when he reaches for something, there is no associated rigidity with movement. Which of the following statement is most accurate?

These are normal findings of aging. These could be related to hyperthyroidism. These are the result of degenerative arthroplasty. The patient should be evaluated for a cerebellar lesion.

Question 18

1 / 1 pts

A patient is not able to perform rapid alternating movements such as patting her knees rapidly. The nurse would document this as:

Ataxia. Astereognosis. Presence of dysdiadochokinesia. Probable abnormality in the cerebellum.

Question 19

1 / 1 pts

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:

Administer the FACT test. Ask the patient to describe his first job. Give him the Four Unrelated Words Test. Ask him to describe what television show he was watching before coming to the clinic.

Question 20

1 / 1 pts

A patient has an injury that affects the posterior columns of the spinal cord. What will the nurse most likely assess in this patient?

Loss of depth perception Changes in the perception of vibration Change in pain perception Alteration in temperature sense

Question 21

1 / 1 pts

The most sensitive indicator of a change in a patient's neurological status is his:

Gross motor movements. LOC (level of consciousness) Speech pattern. Vision

Question 22

1 / 1 pts

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

Percuss and palpate in the lumbar region. Inspect and palpate in the epigastric region. Auscultate and percuss in the inguinal region.

Auscultating the abdomen is begun in the right lower quadrant (RLQ) because: Correct! Bowel sounds are always normally present here Bowel sounds are always normally present here. Peristalsis through the descending colon is usually active. This is the location of the pyloric sphincter. Vascular sounds are best heard in this area.

Question 28

1 / 1 pts

Shifting dullness is a test for: Correct! Ascites Splenic enlargement Inflammation of the kidney Hepatomegaly

Question 29

1 / 1 pts

The medical record indicates that a person has an injury to Broca’s area. When meeting this person, you expect: Correct! Difficulty speaking Visual disturbances Emotional lability Decreased ability to identify smells

Question 30

1 / 1 pts

To elicit the Babinski reflex:

Gently tap the Achilles tendon Stroke the lateral aspect of the sole of the foot from heel to across the ball Present a noxious odor to the person Observe the person walking heel to toe

Question 31

Original Score: 1 / 1 pts

A positive Babinski sign is: Corr Dorsiflexion of the big toe and fanning of all toes Plantar flexion of the big toe with a fanning of all toes The expected response in healthy adults

Withdrawal of the stimulated extremity from the stimulus

Question 32

1 / 1 pts

The cremasteric response:

Is positive when disease of the pyramidal tract is present Is positive when the ipsilateral testicle elevates on stroking of the inner aspect of the thigh Is a reflex of the receptors in the muscles of the abdomen Is not a valid neurologic examination

Question 33

1 / 1 pts

A positive Phalen test and Tinel sign are found in a patient with:

A torn meniscus Hallux valgus Carpal tunnel syndrome Tennis elbow

Question 34

1 / 1 pts

Which type of assessment should be used to evaluate the mental status of a patient with head trauma? Correct!

Glasgow Coma Scale PHQ Perceptual distortion assessment Functional assessment

Question 35

1 / 1 pts

A abdominal hernia is best described as a. Correct!

a protrusion of abdominal contents through a weakening in the abdominal wall. a protrusion of the stomach through the esophageal opening in the diaphragm. an ulcer in the mucosa of the stomach that herniates into the peritoneal cavity. a herniation of the gallbladder into the cystic duct.

Question 36

1 / 1 pts

Abdominal pain radiating to the left shoulder may be indicative of which of the following?

Appendicitis Intussusception

What is the proper sequence of examination for the abdomen?

How to assess bowel sounds?

Which method of examination is used when the nurse takes a patient's radial pulse?

Which method of examination is being used when the nurse's hands are used to assess the temperature of a patient's skin?