exam 4 HA test prep/ test questions



  • **Pulsations between belly button and xiphoid process: abdominal aortic pulsation and if see somewhere else it’s peristalsis so thinking obstruction

  • **person with diarrhea would have hyperactive bowel sounds

    • Constipation = hypoactive bowel sounds

  • **If using laxatives and having diarrhea with have hyperactive bowel sounds

  • **If stomach flu and vomiting then will have hyperactive bowel sounds

    • Nausea, vomiting, gastroenteritis (any irritated bowel or stomach) means hyperactive

  • **Medical issue called peritonitis: inflammation of gut (perineum surrounds our gut (a sac))

    • Hypoactive bowel sounds

  • **We do not palpate abdomen first, we auscultate so we don’t cause a sound

  • **Older adults and looking at abdomen: abdominal musculature gets thinner bc lose muscle mass

  • **Testing for appendicitis: test called McBernies (point between belly button and hip called iliopsoas), if they have pain it’s called McBernie's point → referred pain

    • Rovings sign and McBernies

    • Rebound tenderness + referred pain 

  • **Test for gallbladder/stones: Murphy’s test → press down with force on ribcage on right and tell pt to breath in so if there’s inflammation of gallbladder then it would hit your finger and can’t complete breath

    • If can’t complete breath that’s a positive test for gallstones

  • **Hernia: loop of bowel that is poking through abdominal wall fascia which causes a bump/lump

    • We are NOT worried about every hernia we see in life, only incarcerated

  • Pancreas = LUQ: they will have pain in LUQ (not referred pain) - pancreatitis

  • If someone comes in for abdominal injury they guard abdomen, so ppl with pancreatitis guard bc it’s diffused pain all the way across, tenderness, generally pain of LUQ pain, and sometimes can have Cullen’s sign of Grey Turner’s sign but not all the time

  • **Abdomen on exam and put an “x” where this organ is (place x in right spot of belly)

  • *Know what is normal in bristol stool scale → know 3-5 (soft and brown)

  • **if you saw an abdomen and saw out pouching/bump on abdomen right where umbilical cord is and no changes to still color (and skin is same throughout whole abdomen), then think it’s a hernia

    • Color of skin over hernia does NOT change just looks like normal skin

  • **RLQ pain: appendicitis and doing assessment, you’re going to assess that tender area last 

  • **Know difference between duodenal and gastric ulcers:

    • Who gets them? What risk factors? Better or worse with food?



[More Test Prep Qs]:

  1. What kind of anemia is pernicious anemia

    1. Vitamin B12 deficiency

  2. Duodenal ulcer located where 

    1. Beginning of small intestine N said H had way too much alcohol 

    2. Caused by alcoholism, H. pylori, or too much NSAIDS

      1. Lots of acid-causing ulcer and pain

    3. Pain is relieved by eating

      1. Pain comes back after 2 hours after eating

  3. What to assess with upper GI bleed

    1. Note: patient will tank quickly

    2. Vital signs: Blood pressure (low)/ heart rate (high)

    3. Considered an emergency

  4. What is nursing intervention for a patient with a history of liver cirrhosis and ascites?

    1. Monitor

      1. Respiratory status/Breathing

      2. Daily weights: Distended liver (fluid buildup) 

  5. If the patient is having 10/10 abdominal pain, severe distress, or appendicitis, what do we do first?

    1. Pain meds (assume we have a standing order) 

  6. The appendix is attached to which part of the bowel?

    1. Cecum

  7. Difficulty swallowing is…

    1. Dysphagia

  8. A patient in a motorcycle accident fell on their left side. Think injured spleen; the spleen is enlarged. Palpate? NO

  9. Pulsation between the xiphoid process and umbilicus

    1. Indicates abdominal aortic pulsations

  10. If the patient has peritonitis, what is that?

    1. Inflammation of the peritoneal cavity

    2. What kinds of bowel sounds can we expect?

      1. Hypoactive (so much pressure outside, causes a decrease in bowel sounds)

  11. Why do we auscultate before palpating?

    1. To not disturb bowel sounds (we do least to most invasive) 

  12. What organ is in the lower right quadrant?

    1. Cecum

  13. Patient has black tarry stool. What could be causing it?

    1. GI ulcers (upper): blood is digested and becomes black in stool

  14. What are common findings in the abdominal assessment of older adults?

    1. Thinner abdominal musculature 

    2. Abdominal tone decreases

    3. Decreased GI motility

    4. Abdominal pain reported less frequently

  15. What are we assessing for if patient has appendicitis?

    1. Rebound tenderness: if we’re pressing, we let go and pain is increased

    2. McBerney’s point

  16. What's a loop of the bowel protruding in a weak spot in the abdominal muscle?

    1. Hernia

  17. What's the cause of peptic ulcer disease?

    1. High NSAID use

  18. If a patient comes in with everted (outtie) and large umbilicus, no skin color changes, what could be indicated?

    1. Umbilical hernia

  19. If patient has right lower quadrant pain, what do we examine last?

    1. Right lower pain

  20. The patient is having pain, but then they eat, and it feels better, then 2 hours later, it hurts again 

    1. Duodenal ulcer

  21. The patient is on bed rest, incontinent, gray stool. What is the cause?

    1. Absence of bile pigmentation/Low levels of bile

  22. The patient presents with acute pancreatitis; what do we see with the assessment

    1. Abdominal guarding

    2. Pain and tenderness in the right upper quadrant pain radiating to back

    3. Positive Grey Turner’s sign

  23. The sigmoid colon is where?

    1. Left lower quadrant

  24. What a normal musculoskeletal sign of aging

    1. Lower leg muscle atrophy: Decrease muscle tone on lower legs

    2. Decreased ROM in shoulders

    3. Loss of height

  25. If the patient is at fall risk, and we go to their homes to educate them, what do we tell them?

    1. Avoid throw rugs (bc they flip and slide)

  26. Marked visible peristalsis and distended abdomen, what could that indicate?

    1. Intestinal obstruction 

  27. Patient comes in with a sprained ankle; what kind of assessment first?

    1. Musculoskeletal first

    2. Neurovascular second

  28. What could a nurse say if a patient has pulsation or bulges, what indicates they need education?

    1. “They’re trying to palpate” (DON'T PALPATE)

  29. The patient fractured their leg and was casted 10 hours ago; we gave them opioids which increased pain. What do we check first?

    1. Neurovascular 

  30. The patient has RA and fingers are drifting to the side

    1. Ulnar drift/ ulnar deviation

  31. Towards tops of fingertips in OA patients

    1. Heberden’s nodes

  32. The patient is stiff when getting out of bed, crunching sound when bending down. What do we assess for?

    1. Crepitus

  33. Why do older adults have a decrease in height?

    1. Compression/shortening of vertebral column (spine)

  34. If a patient comes in with an injury and a swollen knee, what do we assess first?

    1. Compare bilaterally (with the other knee) 

  35. If finger joints are getting deformed from RA, why is that?

    1. Autoimmune response

  36. Patients having knee pain, swollen, reddened. What are those signs of?

    1. Injury 

  37. If a patient is eating of brushing teeth, what kind of movement is that?

    1. Flexion

  38. If full resistance and complete ROM against gravity, what would you rate that?

    1. 5

  39. If I tell a patient to touch my finger and nose and they cant, what is that called?

    1. Ataxia

    2. Check for stroke

  40. Inflamed gallbladder is called what?

    1. Cholecystitis

  41. If located on the surface, what is it called?

    1. Dorsal 

  42. What is ROM?

    1. Movement of a joint