exam 4 HA test prep/ test questions

Pulsation between belly button and xiphoid process

Abdominal aortic pulsation. If seen elsewhere, it’s peristalsis, suggesting obstruction.

Diarrhea

Associated with hyperactive bowel sounds.

Constipation

Associated with hypoactive bowel sounds.

Diarrhea from laxative use

Leads to hyperactive bowel sounds.

Stomach flu/Vomiting/Gastroenteritis

Any irritated bowel or stomach causes hyperactive bowel sounds.

Peritonitis

Inflammation of the peritoneal cavity (the sac surrounding the gut).

Bowel sounds in peritonitis

Hypoactive bowel sounds due to external pressure.

Abdominal assessment order

Auscultate before palpating to avoid disturbing bowel sounds and follow least to most invasive order.

Abdominal assessment in older adults

Abdominal musculature gets thinner due to muscle mass loss; abdominal tone decreases; decreased GI motility; abdominal pain reported less frequently.

McBurney's point

A point between the belly button and hip (iliopsoas) used to test for appendicitis; pain indicates McBurney's point, often referred pain.

Appendicitis assessment

Involves checking McBurney's point, Rovsing's sign, rebound tenderness, and referred pain. The RLQ tender area should be assessed last.

Murphy's test

Used to test for gallbladder inflammation/stones. Press down on the right ribcage, ask the patient to breathe in; inability to complete the breath due to pain is a positive sign.

Hernia

A loop of bowel protruding through a weak spot in the abdominal wall fascia, causing a bump/lump. Only incarcerated hernias are a concern; skin color over a hernia does not change.

Umbilical hernia

An everted (outie) and large umbilicus with no skin color changes.

Pancreas location

Left Upper Quadrant (LUQ).

Acute Pancreatitis assessment findings

Abdominal guarding, pain and tenderness in the Left Upper Quadrant (LUQ) radiating to the back, sometimes Cullen's sign or Grey Turner's sign.

Normal Bristol Stool Scale

Types 3-5 (soft and brown).

Assessment order for RLQ pain (e.g., appendicitis)

Assess the tender area last.

Duodenal ulcer location

Beginning of the small intestine.

Causes of duodenal ulcers

Alcoholism, H. pylori, excessive NSAID use (lots of acid-causing pain).

Duodenal ulcer pain and food

Pain is relieved by eating but returns 2 hours after eating.

Pernicious anemia

Vitamin B12 deficiency anemia.

Upper GI bleed

Considered an emergency; patient's condition can tank quickly. Assess vital signs: low blood pressure, high heart rate.

Nursing intervention for liver cirrhosis and ascites

Monitor respiratory status/breathing and daily weights (due to fluid buildup).

First intervention for severe abdominal pain (e.g., appendicitis)

Administer pain medication (assuming standing order).

Appendix attachment

Cecum.

Difficulty swallowing

Dysphagia.

Enlarged spleen

Do NOT palpate, especially after trauma (e.g., motorcycle accident with left-side fall).

Rationale for auscultating before palpating abdomen

To not disturb bowel sounds; follow the least to most invasive assessment order.

Organ in Lower Right Quadrant (LRQ)

Cecum.

Black tarry stool

Caused by upper GI ulcers where blood is digested and becomes black.

Abdominal findings in older adults

Thinner abdominal musculature, decreased abdominal tone, decreased GI motility, abdominal pain reported less frequently.

Appendicitis assessment findings

Rebound tenderness (pain increases upon release of pressure), McBurney’s point.

Bowel protrusion through weak muscle

Hernia.

Cause of Peptic Ulcer Disease (PUD)

High NSAID use.

Everted and large umbilicus, no skin color changes

Umbilical hernia.

Pain pattern relieved by food, then returning 2 hours later

Duodenal ulcer.

Gray stool

Absence of bile pigmentation/low levels of bile.

Sigmoid colon location

Left lower quadrant.

Normal musculoskeletal signs of aging

Lower leg muscle atrophy (decreased muscle tone), decreased ROM in shoulders, loss of height.

Fall risk education (home environment)

Avoid throw rugs (due to potential for flipping/sliding).

Marked visible peristalsis and distended abdomen

Intestinal obstruction.

Initial assessment for sprained ankle

Musculoskeletal assessment first, neurovascular second.

Patient education regarding abdominal pulsations/bulges

Instruct them NOT to palpate ('They’re trying to palpate').

Priority assessment for fractured leg in cast with increased pain post-opioid

Neurovascular assessment.

Fingers drifting to the side with RA

Ulnar drift/ulnar deviation.

Nodes on fingertips in OA patients

Heberden’s nodes.

Stiffness and crunching sound (e.g., bending)

Crepitus.

Cause of decreased height in older adults

Compression/shortening of the vertebral column (spine).

Initial assessment for swollen knee injury

Compare bilaterally (with the other knee).

Cause of finger joint deformity in RA

Autoimmune response.

Knee pain, swollen, reddened

Signs of injury.

Eating or brushing teeth movement

Flexion.

Muscle strength rating: Full resistance, complete ROM against gravity

Rate 5.

Inability to touch finger to nose

Ataxia (check for stroke).

Inflamed gallbladder

Cholecystitis.

Located on the surface

Dorsal.

ROM

Movement of a joint.