HESI Case Studies: N311: Abdomen
Which assessment should the RN complete first?
Since the client is vomiting, the RN should first observe the color and appearance of the emesis for any obvious bleeding or other indications of risk to the pt homeostasis.
Which assessment takes priority while the RN provides oral care?
Because the client has a recent history of n/v, and wt loss, the RN should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness.
To fully assess the client’s bowel patterns, it is essential to to obtain info. related to any difficulty with defecation, such as straining or pain.
What information should the RN obtain next?
The client’s response is the most useful info regarding the nature of his inability to eat spicy foods and any underlying problems.
The RN prepares pt for the physical assessment of the abd. Before assisting him to a supine position, what action should the RN take?
Encourage the client to empty their bladder.
[emptying the bladder will help promote relaxation of the abd wall.]
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[the presence of masses or bulges will alter the symmetry of the abd, resulting in an asymmetric shape.]
[pulsation of the abdominal aorta may be observed in persons with small or average build, but it is often not visible in heavy individuals or those with a distended or protuberant abdomen.]
[Striae are the result of a change in skin pigmentation that occurs following significant stretching of the elastic fibers of the skin on the abdomen. Causes can include ascites (fluid collection in the peritoneal cavity.)]
Change in BMI
[striae are often caused by pregnancy and obesity]
[percussion and palpation may stimulate peristalsis, so inspection and then auscultation should be completed first to ensure accurate assessment of peristalsis.]
What action should the RN take next?
[the RN should determine the frequency of the bs before continuing to the assessment of another quadrant.]
[the nurse should systematically listen for bs in the four quadrants of the abd, which include the RUQ, RLQ.]
right upper and lower quadrants
how should the nurse document the assessment?
[normal bs occur irregularly, approx. 5-30 times per minute.]
[abd vascular sounds are not normally heard, so the only action necessary is to record this normal finding.]
document this normal finding on the client’s assessment record.
What follow-up action should the RN take?
[dullness upon percussion is generally heard over organs and the right costal margin is the location at which abd tympany should change to dullness ovr the liver border. this location is used to determine the liver span.]
[light palpation allow the RN to screen the abd for an obvious masses or tenderness before applying deeper palpation that may cause pain or rigidity.]
[bilateral tensing is often an indication of voluntary guarding by the client. to help distinguish between voluntary and involuntary guarding, the RN should observe the muscles during exhalation because the client usually does not demonstrate voluntary guarding during exhalation. .]
[this info. is essential to report to the RN assuming responsibility for the client to ensure client safety after receiving a sedative.]
[it is important for the RN to describe the appearance of the emesis, which includes the color, the consistency and the volume, or amount, of emesis.]
[after applying pressure at a site away from the area of pain, the RN quickly lifts and removes the hand from the pt abd. Pain upon release of the pressure is referred to as rebound tenderness. ]
[rebound tenderness and involuntary rigidity or guarding are abnormal findings associated with peritoneal irritation and are signs that should be reported to the HCP immediately for further diagnostic evaluation.]
[the RN should begin by gathering further data about the pain including location, intensity, and quality.]
[the client’s subjective report reguarding his pain is the most important info for the RN to assess when evaluating the effectiveness of analgesic administration.