The Gut Instincts and Joint Decisions
When palpating the abdomen of a 28-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with palpation. Which structure is most likely to be involved?
What is spleen?
The spleen is located in the left upper quadrant of the abdomen.
The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?
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
What is B?
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.
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
What is A?
Dullness should be heard where organs are
Put the assessment technique in order for an abdominal assessment.
What is inspect, auscultate, percuss, palpation?
Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
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
What is presence of enlarged organs?
When palpating a patient, the patient reports tenderness to the right lower quadrant of abdomen. What organ could be involved?
What is appendix?
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. Gallbladder inflammation
B. Liver enlargement
C. Kidney inflammation
D. Spleen enlargement
What is C?
Kidney inflammation
How do you assess extension?
What is straightening a limb at a joint?
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as absent bowel sounds, the nurse should listen for at least:
A. 1 minute
B. 5 minutes
C. 10 minutes
D. 2 minutes in each quadrant
What is B?
5 minutes is the appropriate time.
What assessment techniques are used in the musculoskeletal system?
What is inspection and palpation?
How do you assess flexion?
What is have a patient bend a limb at a joint?
A nurse is educating a patient with scoliosis on how physical therapy will help with breathing. Which response by the nurse is correct?
A. Certain exercises can help expand the rib cage increasing lung capacity.
B. The exercises will teach the lungs to support the spine.
C. Physical therapy will teach you to shallow breathe.
D. Exercising causes you to breathe heavily.
What is A?
The nurse is auscultating bowel sounds. Which of the following states is TRUE about bowel sounds?
A. Usually loud, high-pitched, rushing, and tinkling sound
B. 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
What is B?
High-pitched, gurgling, and irregular sounds
Which of the following is the examiner's first action when assessing the musculoskeletal system?
A. Have the patient move the extremities against resistance
B. Feel for the presence of fluid in the joints
C. Observe the patient's joints, muscle and bones for symmetry
D. Check active and passive range of motion for the extremities
What is C?
Which structure is located in the left lower quadrant of the abdomen?
What is Sigmoid colon?
What does subluxation indicate?
What is a dislocation?
What structures are in the right upper quadrant?
What is liver, gallbladder, pancreas, duodenum, right kidney, part of the ascending and transverse colon, small part of stomach, right adrenal gland?
A patient has sustained a fall to the right elbow, what range of motion test can usually rule out a fracture?
What is full extension?
The nurse is performing percussion during an abdominal assessment. What percussion notes can be heard during an abdominal assessment?
What is tympany, hyperresonance, and dullness?
What is syndactyly?
What is webbed fingers?
During an abdominal assessment, the nurse would consider which of these findings as expected?
A. Presence of 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
What is B?
Tympanic percussion note in the umbilical region
What is polydactyly?
What is an extra digit?
When the nurse is inspecting and palpating a patient's hand and fingers, the patient reports tenderness and swelling is visible. What condition should the nurse be suspecting?
What is rheumatoid arthritis?
Which condition is characterized by hard, nontender, noninflammatory nodules?
What is osteoarthritis?
Which findings are expected versus unexpected?
Full range of motion against gravity with full resistance
Patient able to raise leg to 90 degrees
Loud pop/dislocation with open and closing mouth
Decreased pulse strength in extremities
Lifts or shrugs shoulders with abduction
Slight flexion of the hips and knees in older adults
External rotation of the lower leg and foot
Expected:
Full range of motion against gravity with full resistance, patient able to raise leg to 90 degrees, slight flexion of the hips and knees in older adults
Unexpected:
Loud pop/dislocation when opening/closing mouth, decreased pulse strength in extremities, lifts or shrugs shoulders with abduction, external rotation of the lower leg and foot