D443 Health Assessment - Set 5 - Part 1

Correct Answer: To identify areas of tenderness, muscle guarding, and surface characteristics

Light palpation, performed by depressing the abdominal wall about 1 to 2 centimeters, is done first to identify areas of tenderness, muscle guarding, surface masses, and skin characteristics. Beginning with light palpation helps the nurse avoid causing pain, build patient trust, and locate sensitive areas so that deep palpation over those regions can be performed last and with caution.

Correct Answer: Place one hand flat over the costovertebral angle and strike it with the ulnar surface of the other fist

To assess CVA tenderness, the nurse places the palm of one hand flat over the costovertebral angle on the patient's back and delivers a firm blow to that hand with the ulnar surface of the closed fist of the other hand. Normally this produces a dull thud without pain. Sharp pain or tenderness suggests kidney inflammation, such as pyelonephritis or renal calculi.

Correct Answer: Above the symphysis pubis in the midline of the lower abdomen

The bladder lies behind the symphysis pubis and is not normally palpable when empty. As it fills with urine, it rises above the symphysis pubis into the lower midline abdomen and can be palpated or percussed as a smooth, rounded, dull area. A distended, palpable bladder may indicate urinary retention or obstruction requiring further evaluation.

Correct Answer: Palpating in imaginary clock positions moving around the breast in a circular manner

The clock method involves visualizing the breast as a clock face and systematically palpating at each clock-hour position, moving around the breast in a circular fashion and toward the nipple. Findings are documented by clock position and distance from the nipple. This method ensures complete coverage of breast tissue and provides a consistent way to describe the location of any masses.

Correct Answer: Right breast, 2 o'clock position, 3 centimeters from the nipple

A breast mass should be documented using the clock position, the distance in centimeters from the nipple, and the affected breast, along with size, shape, consistency, mobility, and tenderness. For example, right breast, 2 o'clock, 3 cm from nipple gives a precise, reproducible location that allows other clinicians to relocate and monitor the mass over time.

Correct Answer: Upper outer quadrant and axillary tail of Spence

The upper outer quadrant of the breast, including the axillary tail of Spence that extends toward the axilla, contains the largest amount of glandular tissue. Because of this concentration of tissue, it is the most common location for breast tumors. Careful palpation of this quadrant and the axillary tail is essential during a thorough breast examination.

Correct Answer: Axillary (particularly the central) nodes

The majority of lymphatic drainage from the breast, roughly 75 percent, flows to the axillary lymph nodes, especially the central axillary group. Other axillary groups include the pectoral (anterior), subscapular (posterior), and lateral (brachial) nodes. Because breast cancer often spreads through the lymphatic system, palpating the axillary nodes for enlargement or firmness is a critical part of the breast examination.

Correct Answer: To accentuate dimpling, retraction, or skin changes that may indicate an underlying mass

Having the patient raise the arms overhead and press the hands against the hips contracts the pectoral muscles and puts tension on the suspensory ligaments. These maneuvers accentuate skin dimpling, nipple retraction, or asymmetry that may signal an underlying malignancy tethering the tissue. Such retraction signs might not be visible when the patient's arms are simply resting at the sides.

Correct Answer: Lymphatic edema often caused by breast cancer, described as peau d'orange

The thickened, pitted, orange-peel appearance of breast skin is called peau d'orange and results from edema caused by blockage of lymphatic drainage. It is a suspicious finding often associated with inflammatory breast cancer or advanced malignancy. The exaggerated hair follicles create the dimpled texture, and this finding warrants prompt evaluation for underlying malignancy.

Correct Answer: Liver

The lower edge of the liver may sometimes be palpated at or just below the right costal margin, particularly when the patient takes a deep breath, which pushes the diaphragm and liver downward. A normal liver edge feels smooth, firm, and non-tender. The spleen and pancreas are not normally palpable, and a palpable spleen usually indicates enlargement.

Correct Answer: Diverticulitis of the sigmoid colon

The left lower quadrant contains the sigmoid colon, the left ovary and fallopian tube in females, and the left ureter. Diverticulitis, which frequently affects the sigmoid colon, is a common cause of left lower quadrant pain. Appendicitis and cholecystitis produce right-sided pain, and hepatitis causes right upper quadrant discomfort, making sigmoid diverticulitis the best fit for left lower quadrant pain.

Correct Answer: Pain is referred to and felt in the right lower quadrant

A positive Rovsing sign occurs when palpation of the left lower quadrant produces referred pain in the right lower quadrant. This indicates peritoneal irritation associated with appendicitis, as pressure on the descending colon transmits to the inflamed appendix on the right. It is one of several special signs used to support a clinical suspicion of appendicitis.

Correct Answer: The bell of the stethoscope placed over the upper abdomen slightly lateral to the midline

A renal artery bruit is a low-pitched whooshing sound best detected with the bell of the stethoscope placed over the upper abdomen, slightly lateral to the midline just below the costal margin, on each side. The bell is preferred for low-pitched vascular sounds. A bruit in this area may indicate renal artery stenosis and should be reported for further vascular evaluation.

Correct Answer: The right kidney because it is displaced downward by the liver

The right kidney sits slightly lower than the left because it is displaced downward by the large mass of the liver above it. For this reason, the lower pole of the right kidney is more likely to be palpable than the left, especially in thin patients. A normally palpable kidney feels smooth and firm, while enlargement or masses require further investigation.

Correct Answer: Flat or rounded and symmetrical

A normal abdominal contour is flat or rounded and symmetrical, with the umbilicus in the midline and inverted. A scaphoid (sunken) abdomen may occur with malnutrition, while a distended or protuberant abdomen may indicate obesity, ascites, gas, or a mass. Asymmetry, visible peristalsis, or bulging masses are abnormal findings that require further assessment.

Correct Answer: Testing for shifting dullness by percussing with the patient supine and then on the side

Shifting dullness is a percussion technique used to detect ascites. With the patient supine, the nurse percusses to identify borders of tympany (air-filled bowel that floats on top) and dullness (fluid that settles in the flanks). When the patient turns to one side, the fluid shifts and the border of dullness moves, confirming free-flowing fluid in the peritoneal cavity.

Correct Answer: The presence of nausea, changes in bowel habits, or difficulty swallowing

Subjective GI data are symptoms reported by the patient, such as nausea, vomiting, appetite changes, dysphagia (difficulty swallowing), heartburn, abdominal pain, and changes in bowel habits including constipation or diarrhea. Percussion notes, abdominal circumference measurements, and auscultated bowel sounds are objective findings gathered by the examiner, not symptoms reported by the patient.

Correct Answer: Decreased salivation, slowed peristalsis, and increased tendency toward constipation

Normal aging brings decreased salivation, reduced esophageal and intestinal motility (slowed peristalsis), diminished gastric acid secretion, and a greater tendency toward constipation. These are expected physiologic changes. In contrast, absent bowel sounds, rebound tenderness, and a rigid board-like abdomen are abnormal findings suggesting acute pathology such as obstruction or peritonitis regardless of the patient's age.

Correct Answer: Kidneys, ureters, bladder, urethra

Urine is produced in the kidneys, then travels down the ureters to be stored in the bladder, and is finally excreted through the urethra during voiding. Understanding this normal flow helps the nurse localize potential problems, such as obstruction, infection, or reflux, at the appropriate level of the urinary tract during a genitourinary assessment.

Correct Answer: Help the patient relax by flexing the knees and encouraging slow breathing through the mouth

Voluntary guarding is a conscious tightening of the abdominal muscles that can be reduced by promoting relaxation. The nurse should have the patient flex the knees, breathe slowly through the mouth, and palpate during exhalation. If the muscles relax with these measures, the guarding is voluntary. True involuntary rigidity persists despite relaxation techniques and suggests peritoneal inflammation requiring urgent attention.