Assessment and Management of the Acute Abdomen Practice Questions

25 multiple-choice questions on Assessment and management of the acute abdomen for paramedic and EMT students, from Chapter 21 (Abdominal and Gastrointestinal Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. You arrive to find a 58-year-old man with abdominal pain, pale and diaphoretic, with a pulse of 124 and BP of 86/52. What is your priority?

   1. A. Treat for shock and transport
   2. B. Palpate all four quadrants
   3. C. Obtain a full SAMPLE history
   4. D. Auscultate bowel sounds first
   Show answer

   Answer: A. Treat for shock and transport

   Signs of shock outrank a detailed abdominal exam. Manage airway, give oxygen as needed, start IV access en route, and move quickly to a surgical facility.

2. While palpating the abdomen, you should watch the patient's face mainly to:

   1. A. Count his breathing rate
   2. B. Check his pupils for drugs
   3. C. Look for signs of a stroke
   4. D. See pain he may not report
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   Answer: D. See pain he may not report

   Grimacing or wincing during palpation often reveals tenderness that a stoic or older patient will not admit to, and it helps you map the tender area. Pupils, stroke signs, and breathing rate are assessed separately.

3. The usual order of the abdominal exam is:

   1. A. Palpate, inspect, auscultate
   2. B. Auscultate, palpate, inspect
   3. C. Inspect, auscultate, palpate
   4. D. Palpate, auscultate, inspect
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   Answer: C. Inspect, auscultate, palpate

   Inspection comes first, and listening is done before touching because palpation can change bowel sounds. In the field, auscultation adds little and should not delay care.

4. A patient has a distended abdomen that sounds drum-like (tympanic) when tapped. This suggests the swelling is mostly from:

   1. A. Gas-filled bowel
   2. B. Free fluid
   3. C. A solid tumor
   4. D. A full, pregnant uterus
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   Answer: A. Gas-filled bowel

   Tympany on percussion means air, as in a bowel obstruction or ileus. Free fluid such as ascites, a solid mass, and a pregnant uterus all produce dull percussion notes.

5. Before giving ondansetron to a vomiting patient, which known history should make you stop and check the ECG?

   1. A. Mild intermittent asthma
   2. B. Long QT syndrome
   3. C. Sulfa allergy
   4. D. Gastroesophageal reflux
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   Answer: B. Long QT syndrome

   Ondansetron can prolong the QT interval, and the FDA warns against its use in congenital long QT syndrome because of torsades risk. Asthma, reflux, and a sulfa allergy are not contraindications.

6. Rebound tenderness indicates:

   1. A. Bowel obstruction only
   2. B. Renal colic
   3. C. Urinary retention
   4. D. Peritoneal irritation
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   Answer: D. Peritoneal irritation

   Pain on sudden release of pressure means the inflamed peritoneum is jarred. Many EMS systems avoid formal rebound testing because it is painful; asking about pain with bumps or coughing gives similar information.

7. A 6-year-old has abdominal pain, joint pain, and raised purple spots on the backs of the legs and buttocks. You should suspect:

   1. A. A viral rash
   2. B. Strep throat
   3. C. An allergy to a new soap
   4. D. IgA vasculitis (HSP)
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   Answer: D. IgA vasculitis (HSP)

   IgA vasculitis (Henoch-Schonlein purpura) causes palpable purpura on the legs and buttocks, joint pain, and abdominal pain from bowel wall bleeding; it can lead to intussusception and kidney involvement. Viral rashes and allergic reactions do not cause palpable purpura with joint and abdominal pain.

8. A patient with cirrhosis and a tense, massively swollen abdomen becomes short of breath when lying flat. The main reason is that the fluid:

   1. A. Pushes the diaphragm upward
   2. B. Leaks directly into the lungs
   3. C. Irritates the phrenic nerve
   4. D. Raises pressure in the portal vein
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   Answer: A. Pushes the diaphragm upward

   Large-volume ascites raises intra-abdominal pressure, limits diaphragm movement, and reduces lung volumes, especially when supine, so sitting the patient up helps. Ascites can also track into the chest (hepatic hydrothorax), but it does not leak directly into the lungs. The fluid does not irritate the phrenic nerve, and portal hypertension is the cause of the ascites, not the way the fluid affects breathing.

9. A 76-year-old with abdominal pain has HR 92 and BP 104/70. His usual BP is 170/90. How should you interpret this?

   1. A. Normal BP; no concern for shock
   2. B. Hypertension that needs lowering
   3. C. Relative hypotension; suspect shock
   4. D. A false reading from a too-small cuff
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   Answer: C. Relative hypotension; suspect shock

   A pressure that is normal for most people may be 60 to 70 mmHg below a hypertensive patient's baseline and can signal hypoperfusion from bleeding or sepsis. Compare readings with the patient's usual values; a cuff that is too small would read falsely high, not low.

10. A patient with watery diarrhea drank untreated water while camping 10 days ago. This history most suggests:

    1. A. A flare of diverticulitis
    2. B. A parasite such as Giardia
    3. C. A bleeding peptic ulcer in the stomach
    4. D. Early acute appendicitis
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    Answer: B. A parasite such as Giardia

    Giardia and other waterborne pathogens are common after drinking untreated stream or lake water, typically causing diarrhea, bloating, and cramps 1 to 2 weeks after exposure. Travel and exposure history help identify infectious causes; ulcers, diverticulitis, and appendicitis are not linked to this exposure.

11. Which history finding most raises concern for GI bleeding in a patient with abdominal pain?

    1. A. Normal appetite
    2. B. Black, tarry stools
    3. C. Recent travel abroad
    4. D. Mild bloating
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    Answer: B. Black, tarry stools

    Melena means digested blood from an upper GI source. Ask about stool color and vomitus appearance in every abdominal complaint.

12. Which patient with a suspected GI bleed should NOT have orthostatic vital signs checked?

    1. A. One who has a normal heart rate
    2. B. One who passed a single black stool
    3. C. One who is hypotensive lying down
    4. D. One who is alert and oriented
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    Answer: C. One who is hypotensive lying down

    Orthostatic testing adds information only when supine vitals look normal. A patient already hypotensive while lying down is in shock, and sitting or standing him up risks syncope and collapse. Alert, normotensive patients can be tested if needed.

13. Which position is usually most comfortable for a stable patient with abdominal pain?

    1. A. Comfort position, often knees flexed
    2. B. Prone with the arms raised overhead
    3. C. Trendelenburg for every patient
    4. D. Supine and flat with the legs straight
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    Answer: A. Comfort position, often knees flexed

    Flexing the knees relaxes the abdominal wall. Let the stable patient choose; place a vomiting patient with decreased consciousness in the recovery position.

14. A nauseated patient has no IV yet. Which nondrug measure has evidence for short-term nausea relief in the ambulance?

    1. A. Lying flat with the legs raised
    2. B. Drinking a large glass of water
    3. C. Breathing slowly into a paper bag
    4. D. Sniffing an isopropyl alcohol pad
    Show answer

    Answer: D. Sniffing an isopropyl alcohol pad

    Randomized trials in the ED show that inhaling isopropyl alcohol from a prep pad reduces nausea faster than placebo and comparably to oral ondansetron. Drinking a lot may worsen vomiting, and paper-bag rebreathing is unsafe.

15. A 40-year-old with suspected appendicitis rates his pain 8/10. Current evidence on giving an opioid per protocol is that it:

    1. A. Masks the findings surgeons need
    2. B. Should wait for the surgeon's exam
    3. C. Is reserved for pain of 10 of 10
    4. D. Does not hide the diagnosis
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    Answer: D. Does not hide the diagnosis

    Systematic reviews show that opioid analgesia in acute abdominal pain does not increase diagnostic errors or delay surgery, and EMS guidelines support treating moderate to severe pain. Waiting for a surgeon only prolongs suffering.

16. A patient with abdominal pain asks for water. Your best response is:

    1. A. Give 500 mL to prevent dehydration
    2. B. Give sips of juice for sugar
    3. C. Nothing by mouth for now
    4. D. Give milk to coat the stomach
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    Answer: C. Nothing by mouth for now

    Patients who may need surgery or sedation should have nothing by mouth to reduce aspiration risk. Moisten the lips if needed.

17. In an acute abdomen with hypotension, fluid resuscitation should generally aim for:

    1. A. Perfusion, avoiding large volumes
    2. B. A normal BP regardless of volume
    3. C. Withholding all fluids until arrival
    4. D. Oral fluids until IV access is made
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    Answer: A. Perfusion, avoiding large volumes

    In hemorrhage, aggressive fluids can raise pressure, dilute clotting factors, and worsen bleeding. Titrate small boluses to mental status and a radial pulse per protocol.

18. Shortly after a sudden large GI bleed, a hospital hemoglobin level may still look normal because:

    1. A. The spleen quickly makes new red cells
    2. B. Blood is lost as whole blood at first
    3. C. Vomiting concentrates the red cells
    4. D. IV fluids raise the hemoglobin level
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    Answer: B. Blood is lost as whole blood at first

    Early in acute hemorrhage, cells and plasma are lost together, so the concentration does not fall until fluid shifts or IV fluids dilute the blood over hours. A normal early hemoglobin does not exclude major bleeding; IV fluids lower, not raise, the value.

19. Compared with younger adults, older adults with GI bleeding tend to decompensate sooner because they:

    1. A. Have more blood volume
    2. B. Form clots much faster
    3. C. Feel pain much more intensely
    4. D. Have less cardiac reserve
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    Answer: D. Have less cardiac reserve

    Aging reduces the heart's ability to raise rate and output, and coronary and cerebral disease make older adults less tolerant of anemia and low pressure. They do not have more blood volume or faster clotting.

20. Which finding on inspection suggests a bowel obstruction?

    1. A. Flat, soft abdomen with no tenderness
    2. B. Distension with visible peristalsis
    3. C. Bruising around the umbilicus only
    4. D. Pulsing mass just above the navel
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    Answer: B. Distension with visible peristalsis

    Obstruction causes distension and sometimes visible peristaltic waves. A pulsatile mass suggests an AAA.

21. After 500 mL of IV fluid, which finding best shows that a dehydrated vomiting patient is improving?

    1. A. A rise in the blood glucose
    2. B. Increased thirst and dry lips
    3. C. Slower pulse and clearer mentation
    4. D. A higher respiratory rate than before
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    Answer: C. Slower pulse and clearer mentation

    Improving perfusion shows as a falling heart rate, better mental status, warmer skin, and urine output. Persistent thirst and dry lips suggest ongoing dehydration, and a rising respiratory rate may signal acidosis or fluid overload.

22. Which test is a quick screen for peritoneal irritation without deep palpation?

    1. A. Pain when coughing or with heel tap
    2. B. Hyperactive bowel sounds
    3. C. Tenderness at the costovertebral angle
    4. D. Visible distension on inspection
    Show answer

    Answer: A. Pain when coughing or with heel tap

    Pain from coughing, a heel strike, or bumps during transport suggests peritonitis without needing painful rebound testing. Peritonitis tends to quiet the bowel rather than make it hyperactive, distension is nonspecific, and costovertebral angle tenderness points to the kidney.

23. When describing abdominal pain to the receiving team, the most useful location description is:

    1. A. 'Stomach pain,' as the patient says
    2. B. The organ you think is involved
    3. C. The region and the point of worst pain
    4. D. Whether it hurts on the left or the right
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    Answer: C. The region and the point of worst pain

    Reporting the quadrant or region plus the point of maximal tenderness, and any radiation, gives clinicians objective information. Patients' words such as 'stomach' can mean anywhere from chest to pelvis, and naming an organ substitutes a guess for a finding.

24. Which finding in a patient with abdominal pain most calls for early notification of the receiving hospital?

    1. A. Pain rated 6 of 10 since yesterday
    2. B. Hypotension with a rigid abdomen
    3. C. Nausea relieved by an antiemetic
    4. D. A normal blood glucose reading
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    Answer: B. Hypotension with a rigid abdomen

    Shock with peritoneal signs suggests perforation, ruptured aneurysm, or other surgical catastrophe, and early notification lets the hospital ready surgeons, imaging, and blood. The other findings do not indicate time-critical instability.

25. You note fecal-smelling vomit in a patient with distension and no bowel movement for 3 days. This suggests:

    1. A. Distal bowel obstruction
    2. B. Acute gastritis
    3. C. Upper GI bleeding from an ulcer
    4. D. Acute viral hepatitis
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    Answer: A. Distal bowel obstruction

    Feculent vomiting occurs when distal small bowel or colon contents back up. It is a late sign of obstruction with high aspiration risk.