A nurse is precepting a new graduate nurse on the telemetry unit. The new graduate nurse is preparing to perform an abdominal assessment on a hospitalized client without a history of gastrointestinal abnormalities. Click to indicate the corresponding number for each of the following assessment techniques in order of performance.

Percussion

Inspection

Palpation

Auscultation

Answer and Explanation

The Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}

Assessment Technique	1	2	3	4
Percussion				✅
Inspection	✅
Palpation			✅
Auscultation		✅

Rationale:

Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.

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Correct Answer is D

Explanation

A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.

B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.

C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.

D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.

A. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. B. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. C. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. D. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

Correct Answer is A

Explanation

A. Shine a light across the pupil from the side: To assess the pupillary light reflex, the nurse should shine a light across the pupil from the side and observe for both direct and consensual constriction (the constriction of both pupils when one is exposed to light).

B. Follow the penlight: This tests for accommodation (focusing on near objects) rather than the pupillary light reflex.

C. Shine a penlight directly in front: This method doesn’t assess both direct and consensual constriction properly.

D. Focus on a distant object: This assesses accommodation, not the pupillary light reflex.

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Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?

Correct Answer is D

Explanation

When assessing the pupillary light reflex or PERRL (pupils, round, reactive to light), the nurse should use which technique?

Correct Answer is A

Explanation

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

The nurse is testing a patient's visual accommodation, which refers to which action?

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?

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 patient is reporting sharp pain along the costovertebral angles. What does this symptom most often indicate?