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NR 509 FINAL EXAM WITH CORRECT
ANSWERS 2025 GRADED A+
Appendicitis correct answers >> 1. McBurney point tenderness
- Rovsing sign
- the psoas sign
- the obturator sign --Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign, and the psoas sign --The pain of appendicitis classically begins near the umbilicus, then migrates to the RLQ. Older adults are less likely to report this pattern. --Localized tenderness anywhere in the RLQ, even in the right flank, suggests appendicitis. McBurney Point correct answers >> 1. McBurney point lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus
- Appendicitis is three times more likely if there is McBurney point tenderness. Rovsing sign correct answers >> Press deeply and evenly in the LLQ. Then quickly withdraw your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign. Psoas Sign correct answers >> --Place your hand just above the patient's right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient's right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. --Increased abdominal pain on either maneuver is a positive psoas sign, sug-gesting irritation of the psoas muscle by an inflamed appendix. Obturator Sign correct answers >> --Less helpful --Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. --Right hypogastric pain is a positive obturator sign, from irritation of the obturator muscle by an inflamed appendix. This sign has very low sensitivity. Acute Cholecystits correct answers >> RUQ pain Murphy Sign Murphy Sign correct answers >> Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Alternatively, palpate the RUQ with the fingers of your right
Acute Pancreatitis Relieving factors correct answers >> Leaning forward with trunk flexed Acute Pancreatitis Associated Symptoms and Setting correct answers >> Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or gallstones Peptic Ulcer Disease Process correct answers >> Mucosal ulcer in stomach or duode-num >5 mm, covered with fibrin, ex-tending through the muscularis mu-cosa; H. pylori infection present in 90% of peptic ulcers Peptic Ulcer Disease Location correct answers >> Epigastric, may radiate straight to the back Peptic Ulcer Disease Quality correct answers >> Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike No symptoms in up to 20% Peptic Ulcer Disease Timing correct answers >> Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few wks, disappears for months, then recurs
Peptic Ulcer Disease aggravating factors correct answers >> Variable Peptic Ulcer Disease relieving factors correct answers >> Food and antacids may bring re-lief (less likely in gastric ulcers) Peptic Ulcer Disease associated symptoms and setting correct answers >> Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight loss (more common in gastric ulcer); dyspepsia is more com-mon in the young (20-29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30-60 yrs GERD Process correct answers >> Prolonged exposure of esophagus to gastric acid due to impaired esopha-geal motility or excess relaxations of the lower esophageal sphincter; Helico-bacter pylori may be present GERD Location correct answers >> Chest or epigastric GERD Quality correct answers >> Heartburn, regurgitation GERD timing correct answers >> After meals, especially spicy foods GERD aggravating factors correct answers >> Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter
Diverticulitis associated symptoms and setting correct answers >> Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness Hepatitis correct answers >> -Tenderness over liver (liver inflammation) --Hep A and B prevention: Vaccination Hep A: spread through fecal matter and asymptomatic children Hep B: 1% fatality, 15-25% of chronic infection die from cirrhosis or liver cancer (usually asymptomatic until onset of advanced liver disease). Hep C: Mainly percutaneous exposure. Hepatitis B high risk correct answers >> -Sexual contact: w/ partners infected, more than one parter in prior 6 mos, people seeing eval of treatment for STD, men with men -Perc and Mucosal exposure to blod: drugs, household contacts, residents and staff of facilties of DD, Health care, dialysis -Others: Travel to endemic areas, chronic liver disease and HIV, people seeking protection from Hep B. --All adults in high risk-settings: STD clinics, HIV programs, Drug programs, correctional facilities, programs for gay men, chronic hemodialysis facilities, facilities for people with Developmental Delays. IBS patterns correct answers >> 1. diarrhea—predominant
- constipation—predominant
- mixed. --Symptoms present ≥6 mo and abdominal pain for ≥3 mo plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance) IBS: process correct answers >> Altered motility or secretion from luminal and mucosal irritants that change mucosal permeability, immune activation, and colonic transit, including maldigested carbohydrates, fats, excess bile acids, gluten intolerance, entero- endocrine signaling, and changes in microbiomes IBS characteristics of stool correct answers >> Loose; ∼50% with mucus; small to mod-erate volume. Small, hard stools with constipation. May be mixed pattern. IBS timing correct answers >> Worse in the morning; rarely at night. IBS associated symptoms correct answers >> Crampy lower ab- dominal pain, ab-dominal disten-tion, flatulence, nausea; urgency, pain relieved with defecation IBS setting, persons at risk correct answers >> Young and middle- aged adults, especially women
Urge incontinence mechanism correct answers >> Decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above the sacral level. Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal impaction. Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder volumes. Urge incontinence symptoms correct answers >> Involuntary urine loss preceded by an urge to void. The volume tends to be moderate. Urgency, frequency, and nocturia with small to moderate volumes. If acute inflammation is present, pain on urination. Possibly "pseudo-stress incontinence"—voiding 10-20 sec after stresses such as a change of position, going up-or downstairs, and possibly coughing, laughing, or sneezing. Urge incontinence physical signs correct answers >> The small bladder is not detectable on abdominal examination. When cortical inhibition is decreased, mental deficits or motor signs of central nervous system disease are often present. When sensory pathways are hyperexcitable, signs of local pelvic problems or a fecal impaction may be present. Overflow incontinence problem correct answers >> Detrusor contractions are insufficient to overcome urethral resistance, causing
urinary retention. The bladder is typically flaccid and large, even after an effort to void. Overflow incontinence mechanisms correct answers >> Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle associated with peripheral nerve disease at S2-4 level. Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy. Overflow incontinence symptoms correct answers >> When intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues. Decreased force of the urinary stream. Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present. Overflow incontinence physical signs correct answers >> Examination often reveals an enlarged, sometimes tender, bladder. Other signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes. Functional incontinence problem correct answers >> The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions.
Colorectal cancer screening correct answers >> Adults ages 50 to 75 years—options (grade A recommendation)
- Hi-sens fecal occult blood testing annually
- Sigmoidoscopy every 5 years w/ high-sensitivity FOBT every 3 years
- Screening colonoscopy every 10 years B: Adults 76-
- Screening not advised because the benefits are small in comparison to the risks
- Use individual decision making if screening an adult for the first time C. Adults older than age 85 years—do not screen (grade D recommendation)
- Screening not advised because "competing causes of mortality preclude a mortality benefit that outweighs harms" Colorectal cancer screening tests correct answers >> 1. Stool tests that detect occult fecal blood: a. fecal immunochemical tests, b. high- sensitivity guaiac-based tests, c. tests that detect abnormal DNA.
- Endoscopic tests: a. colonoscopy, which visualizes the entire colon and can remove polyps, b. flexible sigmoidoscopy, which visualizes the distal 60 cm of the bowel. --Colonoscopy is the most commonly used and gold standard, though people may prefer other tests like FOBTs because they are safer and easier to perform.
Colorectal cancer epidemiology correct answers >> --Third most frequently diagnosed cancer among both men and women (over 140,000 new cases) and the third leading cause of cancer death (nearly 50,000 deaths) each year in the United States. --The lifetime risk of diagnosis with colorectal cancer is about 5%, while the lifetime risk for dying from colorectal cancer is about 2%. Colorectal cancer risk factors correct answers >> 1. Increasing age
- personal history of colorectal cancer
- adenomatous polyps, or long-standing inflammatory bowel disease
- family history of colorectal neoplasia—particularly multiple first- degree relatives, a single first-degree relative diagnosed before age 60 years, or a hereditary colorectal cancer syndrome. Weaker risk factors:
- male sex
- African American race
- tobacco use
- excessive alcohol use
- red meat consumption
- obesity. Colorectal cancer prevention correct answers >> Primary prevention:
- screen for and
Abdomen percussion correct answers >> --Tympany dominates d/t gas --Dull areas: fluid, feces, mass, enlarged organ --Protuberant abdomen: note where tympany changes to dullness (solid posterior structures) --Percuss lower anterior chest above costal margins: normal= right dullness over liver, left tympany over gastric air bubble and spelnic flexure of colon. Abdomen palpation correct answers >> gently palpate over 4 quadrants: abnormal: involuntary rigidity=peritoneal inflammation Deep palpation to feel for masses: physiologic (pregnancy), inflammatory (diverticulitis), vascular (AAA), neoplastic (colon cancer), or obstructive (distended bladder or dilated loop of bowel) Liver assessment correct answers >> Percussion: liver span should be about 4-8cm in midsternal line and 6-12cm in right midclavicular line. Palpation ("hooking technique" may be helpful):
- start below line of dullness of lower liver border and press gently in and up.
- Have pt take deep breath in and feel liver edge (soft, sharp, and regular with smooth surface, non-tender).
- Inspiration: liver is palpable 3cm below right costal margin in midclavicular line. (gallbladder may merge with liver causing firm oval mass below liver edge) Percussion tenderness in nonpalpable liver: strike right side with ulnar surface of hand and compare to sensation felt on left side: tenderness suggests inflammation (hepatitis or congestion from heart failure). Spleen assessment correct answers >> Enlargement: expands anteriorly, downward, and medially, replacing tympany of stomach and colon with dullness of solid organ. Percussion:
- Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin, an area termed Traube space. As you percuss along the route, note the lateral extent of tympany. Percussion is moderately accurate in detecting splenomegaly (80% of the time)
- If tympany is prominent, splenomegaly is unlikely.
- Check for a splenic percussion sign. Percuss the lowest interspace in the left anterior axillary line (usually tympanic). Have patient to take a deep breath, and percuss again. When spleen size is normal, the percussion note usually remains tympanitic. Palpation (supine and on right side): Splenomegaly is eight times more likely when the spleen is palpable (portal hypertension, hematologic malignancies, HIV infection, infiltrative diseases like amyloidosis, and splenic infarct or hematoma). In 5% of normal adults: Spleen tip, is just palpable deep to the left costal margin.
the patient's right side. Use your left hand to lift up from the back, and your right hand to feel deep in the RUQ. Proceed as before. The kidney may be slightly tender. The patient is usually aware of a capture and release. Causes of kidney enlargement include hydronephrosis, cysts, and tumors. Bilateral enlargement suggests poly-cystic kidney disease. Kidney Percussion correct answers >> assess percussion tenderness over the CVAs. Pressure from your fingertips may be enough to elicit tenderness; if not, use fist percussion. Place the ball of one hand in the CVA and strike it with the ulnar surface of your fist (Fig. 11-29). Use enough force to cause a perceptible but painless jar or thud. Pain with pressure or fist percussion supports pyelonephritis if associated with fever and dysuria, but may also be musculoskeletal. Bladder assessment correct answers >> Percussion dullness: bladder must be 400-600ml full for dullness to appear. Palpation: dome of distended bladder feels smooth, round, nontender. Causes of bladder distention: outlet obstruction from a urethral stricture or prostatic hyperplasia, medication side effects, and neurologic disorders such as stroke or multiple sclerosis. Suprapubic tenderness is common in bladder infection. Aorta assessment correct answers >> Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations
Adults over age 50 years, assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta (normally no more than 3cm wide). Aorta abnormalities correct answers >> A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA. Sensitivity of palpation increases as AAAs enlarge. Risk factors for AAA correct answers >> 1. Age ≥65 years
- history of smoking
- male gender
- first-degree relative with a history of AAA repair Ascites assessment correct answers >> A protuberant abdomen with bulging flanks is suspicious for ascites dullness appears in the dependent areas of the abdomen. Test for shifting dullness: site of dullness shifts when pt turns to one side. Test for fluid wave: have someone hold both sides of abdomen and sharply tap top part of abdomen and feel for fluid to shift to lower part. A positive fluid wave, shifting dullness, and peripheral edema makes the presence of ascites to three to six times more likely Breast Exam Males correct answers >> Enlargement: gynecomastia
