Nursing Assessment Chapter 11: Abdomen NCLEX Questions

The nurse is percussing the seventh right intercostal space at the mid-clavicular line over the liver. Which sound should the nurse expect to hear?

A. Dullness

B. Tympany

C. Resonance

D. Hyperresonance

A. Dullness

Liver is located in the R Upper Quadrant.

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

A. Liver

B. Duodenum

C. Gallbladder

D. Sigmoid colon

D. Sigmoid colon

A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:

A. Aphasia

B. Dysphasia

C. Dysphagia

D. Anorexia

C. Dysphagia

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

A. Percuss and palpate in the lumbar region

B. Inspect and palpate in the epigastric region

C. Auscultate and percuss in the inguinal region

D. Percuss and palpate the midline area above the suprapubic bone

D. Percuss and palpate the midline area above the suprapubic bone

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:

A. Increased salivation

B. Increased liver size

C. Increased esophageal emptying

D. Decreased gastric acid secretion

D. Decreased gastric acid secretion

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 handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is TRUE regarding assessment of the spleen in this situation?

A. The spleen can be enlarged as a result of trauma

B. The spleen is normally felt on routine palpation

C. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size.

D. An enlarged spleen should not be palpated because it can easily rupture.

D. An enlarged spleen should not be palpated because it can easily rupture.

A patients abdomen is bulging and stretched in appearance. The nurse should describe this finding as:

A. Obese

B. Herniated

C. Scaphoid

D. Protuberant

D. Protuberant

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ______ profile.

A. Flat

B. Convex

C. Bulging

D. Concave

D. Concave

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

A. Pulsations of the renal arteries

B. Pulsations of the inferior vena cava

C. Normal abdominal aortic pulsations

D. Increased peristalsis form a bowel obstruction

C. Normal abdominal aortic pulsations

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:

A. Diarrhea

B. Peritonitis

C. Laxative use

D. Gastroenteritis

B. Peritonitis

The nurse is watching a new graduate nurse perform auscultation of a patients abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

A. We need to determine the areas of tenderness before using percussion and palpation

B. Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation

C. Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination.

D. Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.

B. Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation

The nurse is listening to bowel sounds. Which of these statements is TRUE of bowel sounds? Bowel sounds:

A. Are usually loud, high-pitched, rushing, and tinkling sounds.

B. Are usually high-pitched, gurgling, and irregular sounds.

C. Sound like two pieces of leather being rubbed together.

D. Originate from the movement of air and fluid through the large intestine.

B. Are usually high-pitched, gurgling, and irregular sounds.

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

A. Loud continual hum.

B. Peritoneal friction rub.

C. Hypoactive bowel sounds.

D. Hyperactive bowel sounds.

D. Hyperactive bowel sounds.

During an abdominal assessment, the nurse would consider which of these findings as normal?

A. Presence of a bruit in the femoral area

B. Tympanic percussion note in the umbilical region

C. Palpable spleen between the ninth and eleventh ribs in the left mid-axillary line

D. Dull percussion note in the left upper quadrant at the mid-clavicular

B. Tympanic percussion note in the umbilical region

The nurse is assessing the abdomen of a pregnant woman who is complaining of having acid indigestion all the time. The nurse knows that esophageal reflux during pregnancy can cause:

A. Diarrhea.

B. Pyrosis.

C. Dysphagia.

D. Constipation

B. Pyrosis.

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:

A. Flatness, resonance, and dullness.

B. Resonance, dullness, and tympany.

C. Tympany, hyperresonance, and dullness.

D. Resonance, hyperresonance, and flatness.

C. Tympany, hyper-resonance, and dullness.

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:

A. Increased gastric acid secretion.

B. Decreased gastric acid secretion.

C. Delayed gastrointestinal emptying time.

D. Increased gastrointestinal emptying time.

B. Decreased gastric acid secretion.

A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of:

A. Ovary infection.

B. Liver enlargement.

C. Kidney inflammation.

D. Spleen enlargement.

C. Kidney inflammation.

A nurse notices that a patient has ascites, which indicates the presence of:

A. Fluid.

B. Feces.

C. Flatus.

D. Fibroid tumors.

A. Fluid.

The nurse knows that during an abdominal assessment, deep palpation is used to determine:

A. Bowel motility.

B. Enlarged organs.

C. Superficial tenderness.

D. Overall impression of skin surface and superficial musculature.

B. Enlarged organs.

The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be:

A. Gallbladder disease.

B. Overuse of laxatives.

C. Gastrointestinal bleeding.

D. Localized bleeding around the anus.

C. Gastrointestinal bleeding.

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?

A. Spleen

B. Sigmoid

C. Appendix

D. Gallbladder

C. Appendix

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is TRUE?

A. Abdominal tone is increased.

B. Abdominal musculature is thinner.

C. Abdominal rigidity with an acute abdominal condition is more common.

D. The older adult with an acute abdominal condition complains more about pain than the younger person.

B. Abdominal musculature is thinner.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by:

A. Projectile vomiting.

B. Hypoactive bowel activity.

C. Palpable olive-sized mass in the right lower quadrant.

D. Pronounced peristaltic waves crossing from right to left.

A. Projectile vomiting.

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?

A. A bruit is absent.

B. Femoral pulses are increased.

C. A pulsating mass is usually present.

D. Most are located below the umbilicus

C. A pulsating mass is usually present.

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patients abdomen. Before reporting this finding as SILENT BOWEL SOUNDS, the nurse should listen for at least:

A. 1 minute.

B. 5 minutes.

C. 10 minutes.

D. 2 minutes in each quadrant.

B. 5 minutes.

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?

A. Obturator test

B. Test for Murphy sign

C. Assess for rebound tenderness

D. Iliopsoas muscle test

B. Test for Murphy sign

Just before going home, a new mother asks the nurse about the infants umbilical cord. Which of these statements is correct?

A. It should fall off in 10 to 14 days.

B. It will soften before it falls off.

C. It contains two veins and one artery.

D. Skin will cover the area within 1 week.

A. It should fall off in 10 to 14 days.

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?

A. Dullness across the abdomen

B. Flatness in the right upper quadrant

C. Hyperresonance in the left upper quadrant

D. Tympany in the right and left lower quadrants

A. Dullness across the abdomen

A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?

A. No need to worry. Most men your age develop hernias.

B. A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

C. A hernia is the result of prenatal growth abnormalities that are just now causing problems.

D. Ill have to have your physician explain this to you.

B. A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should:

A. Document the presence of hepatomegaly.

B. Ask additional health history questions regarding his alcohol intake.

C. Describe this dullness as indicative of an enlarged liver, and refer him to a physician.

D. Consider this finding as normal, and proceed with the examination.

D. Consider this finding as normal, and proceed with the examination.

A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?

A. Spleen

B. Sigmoid colon

C. Appendix

D. Gallbladder

A. Spleen

The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.

The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group?

A. Blacks

B. Hispanics

C. Whites

D. Asians

A. Blacks

The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem?

A. Hypertension

B. Streptococcal infections

C. Recurrent constipation with frequent laxative use

D. Frequent use of nonsteroidal antiinflammatory drugs

D. Frequent use of nonsteroidal antiinflammatory drugs

During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to:

A. Enlarged liver.

B. Enlarged spleen.

C. Distended bowel.

D. Excessive diarrhea.

A. Enlarged liver.

The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

During an assessment, the nurse notices that a patients umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition?

A. Intra-abdominal bleeding

B. Constipation

C. Umbilical hernia

D. Abdominal tumor

C. Umbilical hernia

The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:

A. Splenomegaly.

B. Distended bladder.

C. Constipation.

D. Ascites.

D. Ascites.

If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?

The nurse should:

A. Examine the tender area first.

B. Examine the tender area last.

C. Avoid palpating the tender area.

D. Palpate the tender area first, and then auscultate for bowel sounds.

B. Examine the tender area last.

The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

During a health history, the patient tells the nurse, I have pain all the time in my stomach. Its worse 2 hours after I eat, but it gets better if I eat again! Based on these symptoms, the nurse suspects that the patient has which condition?

A. Appendicitis

B. Gastric ulcer

C. Duodenal ulcer

D. Cholecystitis

C. Duodenal ulcer

Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may relieved by more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.

Multiple Response:

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.

a. Test for the Murphy sign

b. Test for the Blumberg sign

c. Test for shifting dullness

d. Perform the iliopsoas muscle test

e. Test for fluid wave

b. Test for the Blumberg sign
d. Perform the iliopsoas muscle test

Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites.

The organ in the right upper quadrant of the abdomen is the:

A. spleen.

B. liver.

C. cecum.

D. sigmoid colon

B. Liver.

The liver is in the right upper quadrant of the abdomen. The spleen is in the left upper quadrant. The cecum is in the right lower quadrant. The sigmoid colon is in the left lower quadrant.

The abdomen normally moves with breathing until the age of __ years.

A. 4

B. 7

C. 14

D. 75

B. 7

Abdominal breathing in children continues until the age of 7 years.

Moles on the abdomen:

A. are common.

B. are uncommon

C. require a biopsy.

D. are no cause for concern.

A. are common.

Pigmented nevi (moles) are common on the abdomen. Nevi are circumscribed brown macular or papular areas. Nevi should be observed for unusual color or change in shape; biopsy or removal is indicated if nevi change, which indicates a possible malignancy.

Older adults have:

A. decreased salivation leading to dry mouth.

B. increased gastric acid secretion.

C. increased liver size.

D. decreased incidence of gallstones.

A. decreased salivation leading to dry mouth.

Aging results in decreased salivation leading to dry mouth. Aging results in decreased gastric acid secretion. Aging results in decreased liver size. Aging results in increased incidence of gallstone formation.

The four layers of large, flat abdominal muscles form the:

A. linea alba.

B. rectus abdominus

C. ventral abdominal wall.

D. viscera.

C. ventral abdominal wall.

The four layers of large, flat muscles form the ventral abdominal wall. These muscles are joined at the midline by a tendinous seam, the linea alba. One set of abdominal muscles, the rectus abdominis, forms a strip extending the length of the midline. The viscera are all the internal organs inside the abdominal cavity.

Ascites is defined as:

A. a bowel obstruction.

B. a proximal loop of the large intestine.

C. an abnormal enlargement of the spleen.

D. an abnormal accumulation of serous fluid within the peritoneal cavity.

D. an abnormal accumulation of serous fluid within the peritoneal cavity.

Ascites is free fluid in the peritoneal cavity. A bowel obstruction may result in abdominal distention. The proximal loop of the large intestine is the ascending colon. Splenomegaly is the term to describe an enlarged spleen.

Pyrosis is:

A. an inflammation of the peritoneum.

B. a burning sensation in the upper abdomen.

C. a congenital narrowing of the pyloric sphincter.

D. an abnormally sunken abdominal wall.

B. a burning sensation in the upper abdomen


Pyrosis (heartburn) is a burning sensation in the esophagus and stomach from reflux of gastric acid. Peritonitis is an inflammation of the peritoneum. Pyloric stenosis is a congenital narrowing of the pyloric sphincter. A scaphoid abdomen abnormally caves in or is sunken.

The symptoms occurring with lactose intolerance include:

A. bloating and flatulence.

B. gray stools.

C. hematemesis.

D. anorexia.

A. bloating and flatulence.


Lactose intolerance produces abdominal pain, bloating, and flatulence when milk products are consumed. Gray stools may occur with hepatitis. Hematemesis occurs with stomach or duodenal ulcers and esophageal varices. Anorexia is a loss of appetite and occurs with gastrointestinal disease, as a side effect of some medications, with pregnancy, or with psychological disorders.

Methods to enhance abdominal wall relaxation during examination include:

A. a cool environment.

B. having the patient place arms above the head.

C. examining painful areas first.

D. positioning the patient with the knees bent.

D. positioning the patient with the knees bent.


Position the patient supine, with the head on a pillow, knees bent or on a pillow, and arms at the side. Keep the room warm to avoid chilling and tensing of muscles. Avoid having arms above the head; this increases abdominal wall tension. Painful areas should be examined last to avoid muscle guarding.

Pyloric stenosis is a(n):

A. abnormal enlargement of the pyloric sphincter.

B. inflammation of the pyloric sphincter.

C. congenital narrowing of the pyloric sphincter.

D. abnormal opening in the pyloric sphincter.

C. congenital narrowing of the pyloric sphincter.

Pyloric stenosis is a congenital defect causing a narrowing of the pyloric sphincter.