HESI Case Studies: N311: Abdomen
The pt vomits into the emesis basin and then remains sitting on the side of the bed, stating he may need to vomit again.
Which assessment should the RN complete first?
Observe the color of the emesis.
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.
Pt continues to feel nauseated. After the RN administers the antiemetic, pt states they feel better. The RN offers to provide oral care with a mint flavored swab and cool water.
Which assessment takes priority while the RN provides oral care?
Observe for excessive dryness of the mucus membranes.
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.
The RN begins the client interview, focusing on the GI system. For the RN to learn about the client’s bowel patterns, which info is most important to obtain from the pt?
Any difficulty with defecation.
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.
The nurse asks pt if there are any foods he cannot eat. He reports that he can’t eat spicy foods.
What information should the RN obtain next?
What happens when the client eats spicy foods.
The client’s response is the most useful info regarding the nature of his inability to eat spicy foods and any underlying problems.
Pt reports severe indigestion and heartburn after eating Mexican foods, the RN is ready to begin the physical assessment of the abdomen.
The RN prepares pt for the physical assessment of the abd. Before assisting him to a supine position, what action should the RN take?
Put on the room lights and ensure the room temperature is comfortable. [a brightly lit room aids the RN in accurate assessment. A chilled environment can increase muscle tension.]
Encourage the client to empty their bladder.
[emptying the bladder will help promote relaxation of the abd wall.]
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To assess the symmetry of the abd, which action should the nurse take?
inspect for masses or bulges.
[the presence of masses or bulges will alter the symmetry of the abd, resulting in an asymmetric shape.]
The RN does not observe any pulsation of the abdominal aorta. The RN recognizes that this is consistent with what other assessment finding?
protuberant abdominal contour.
[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.]
While inspecting pt abdomen, the RN observes striae on the lower abdomen. In response to this finding, what information should the nurse obtain?
Past medical history of ascites.
[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]
To ensure the most accurate assessment of peristalsis, what action should the RN take?
[percussion and palpation may stimulate peristalsis, so inspection and then auscultation should be completed first to ensure accurate assessment of peristalsis.]
The RN hears high-pitched gurgling noises in the RLQ.
What action should the RN take next?
Note how frequently the sounds occur before moving to another quadrant.
[the RN should determine the frequency of the bs before continuing to the assessment of another quadrant.]
it is essential for the RN to listen for bs in which areas?
[the nurse should systematically listen for bs in the four quadrants of the abd, which include the RUQ, RLQ.]
right upper and lower quadrants
the RN listens an hears gurgling sounds at each location and hear between 8 and 20 sounds per minute.
how should the nurse document the assessment?
[normal bs occur irregularly, approx. 5-30 times per minute.]
The RN auscultates, but does not hear any abd vascular sounds. What action should the RN take in response to this finding?
Continue to monitor
[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.
While percussing, the RN hears a dull sound while percussing the suprapubic area. What action should the RN take in response to this finding?
observe the are for bladder distention.
while percussing the abd, the RN hears tympany over the entire abd but notes a duller sounds when percussing the right costal margin.
What follow-up action should the RN take?
note this location as the border of the liver.
[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.]
The RN’s goal in palpating the client’s abd is to screen for ant masses or tenderness. To achieve this goal, what action should the RN take first?
Lightly palpate the abd surface.
[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.]
While palpating, the RN observes that the client’s superficial abd muscles are tensing bilaterally. What action should the RN take?
observe the muscles while the client exhales.
[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. .]
After palpating the pt abd, the pt is fatigues and states that the nausea medication has made him very sleepy. The RN concludes the assessment to allow Calvin to rest. Which info is most important to report to the RN assuming responsibility for Calvin’s care?
the time the client received an antiemetic.
[this info. is essential to report to the RN assuming responsibility for the client to ensure client safety after receiving a sedative.]
During report, the RN describes the client’s earlier emesis. The RN should describe the emesis in terms of which characteristics?
color and volume.
[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.]
The RN asks pt where they are having pain, he points to right lower abd. When completing the pain assessment, how should the RN assess for rebound tenderness?
Push down on the left side of the abd.
[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. ]
after observing the presence of rebound tenderness, the RN notes the onset of involuntary rigidity of the client’s abd. Which action should the nurse implement?
notify the HCP of the findings.
[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.]
After pt surgery, pt seems anxious and tells RN that he hurts a lot. In response to the client statement that he hurts a lot, what action should the RN take first?
ask the client where he is experiencing the pain.
[the RN should begin by gathering further data about the pain including location, intensity, and quality.]
Which finding provides the most useful data about the effectiveness of medication given to the pt?
the client denies any lessening of his pain.
[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.
to learn about the intensity of the client’s pain, what action should the RN take?
encourage the client to use a numeric pain scale to rate his pain.