D443 Health Assessment - Set 4 - Part 3

Correct Answer: A normal respiratory rate for a resting adult

The normal respiratory rate for a resting adult is generally 12 to 20 breaths per minute, with regular rhythm and effortless breathing. A rate of 14 breaths per minute that is regular and unlabored falls within this normal range and requires no intervention. Bradypnea is a rate below about 12, and tachypnea is a rate above about 20.

Correct Answer: Inspection, auscultation, percussion, palpation

Unlike most body systems, the abdomen is assessed using inspection, auscultation, percussion, and then palpation. Auscultation is performed before percussion and palpation because pressing on or tapping the abdomen can stimulate the bowel and artificially increase or alter bowel sounds, leading to inaccurate assessment of intestinal motility.

Correct Answer: Listen for 5 full minutes in each quadrant

Bowel sounds normally occur every 5 to 30 seconds, but their irregular timing means the nurse must listen for a full 5 minutes in a quadrant before concluding that bowel sounds are absent. Absent bowel sounds after a full 5-minute assessment may indicate a serious condition such as paralytic ileus or peritonitis and warrant prompt reporting.

Correct Answer: Right lower quadrant

McBurney's point is located in the right lower quadrant, approximately one-third of the distance from the anterior superior iliac spine to the umbilicus. Localized tenderness at McBurney's point is a classic sign of appendicitis because the appendix is situated in the right lower quadrant, making it a key landmark during abdominal assessment.

Correct Answer: Sharp pain occurs at the moment the nurse quickly releases the pressure

Rebound tenderness, also called Blumberg's sign, is positive when the patient experiences sharp pain upon the sudden release of pressure rather than during the pressing itself. This finding suggests peritoneal irritation or inflammation, such as in appendicitis or peritonitis. Because the maneuver can cause significant discomfort, it is typically performed near the end of the abdominal examination.

Correct Answer: 6 to 12 centimeters

The normal liver span at the right midclavicular line is approximately 6 to 12 centimeters in a healthy adult. The upper border is identified by percussing dullness where lung resonance changes, and the lower border is found where tympany of the abdomen changes to dullness. A span greater than 12 centimeters may indicate hepatomegaly, while an unusually small span may suggest liver atrophy.

Correct Answer: Liver and gallbladder

The right upper quadrant contains the liver, gallbladder, portions of the duodenum, the head of the pancreas, and the hepatic flexure of the colon. Right upper quadrant tenderness commonly points to conditions such as cholecystitis, hepatitis, or biliary disease. The spleen is in the left upper quadrant, the appendix in the right lower quadrant, and the sigmoid colon in the left lower quadrant.

Correct Answer: The patient abruptly stops inspiration due to sharp pain

A positive Murphy's sign occurs when the patient abruptly halts inspiration because of sharp pain as the inflamed gallbladder descends and contacts the examiner's fingers under the right costal margin. This finding strongly suggests acute cholecystitis. The sudden cessation of breath is the hallmark of the test, reflecting acute inflammation of the gallbladder.

Correct Answer: Borborygmi (hyperactive bowel sounds)

Hyperactive bowel sounds, described as loud, high-pitched, and rushing, are called borborygmi. They reflect increased intestinal motility and may occur with diarrhea, early bowel obstruction, gastroenteritis, or hunger. A bruit is a vascular whooshing sound over an artery, and a friction rub is a grating sound over an inflamed organ, both of which are distinct from bowel sounds.

Correct Answer: Tympany, indicating air in the underlying intestines

Tympany is the high-pitched, hollow, drum-like sound normally heard over most of the abdomen because of air within the stomach and intestines. It is the predominant expected percussion note in a healthy abdomen. Dullness is heard over solid organs like the liver or a full bladder, and its presence in unexpected areas may indicate a mass, organ enlargement, or fluid.