HESI Case Study: Abdominal Assessment

Mr. Dunner is admitted to his room accompanied by his wife. Before the registered nurse (RN) can begin the admission assessment, Mr. Dunner states he needs to “Throw up”. The RN helps him to sit up and provides and emesis basin.

Mr. Dunner vomits into the emesis basin and then remains sitting on the side of the bed, stating that he may need to “throw up” again.

1. What assessment should the RN complete first?

-Auscultate the bowel sounds
-Observe the color of the emesis
-Ask about recent loss of appetite
-Palpate for abdominal distention

-Observe the color of the emesis
Mr. Dunner continues to feel nauseated. Mrs. Dunner remains with her husband while the RN leaves the room to prepare the PRN dose of a prescribed antiemetic.

Shortly after the RN administers the antiemetic, Mr. Dunner states he feels “better”. The RN offers to provide oral care with a mint-flavored foam swab and cool water.

2. Which assessment takes priority while the RN provides oral care?
-Palpate the salivary glands for tenderness or swelling
-Observe for excessive dryness of the mucus membranes
-Check for deviation when the client sticks out his tongue
-Assess the side of the oral cavity for any open sores

Observe for excessive dryness of the mucus membrane
Fifteen minutes after receiving the antiemetic, Mr. Dunner has stopped vomiting, appears relaxed, and denies further nausea. He states that he is comfortable enough for the RN to being the admission assessment and asks the RN to call him Calvin.

3. The RN begins the client interview, focusing on the gastrointestinal system. For the RN to learn about the client’s bowel patterns, what information is most important to obtain from Mr. Dunner?

-Any difficulty with defecation
-Presence of abdominal distention
-Recent onset of flatulence
-Amount of fiber in the diet

-Any difficulty with defecation
The nurse asks Calvin if there are any food he cannot eat. He reports that he can’t eat spicy foods.

4. What information should the RN obtain next?

-When the client developed his intolerance to spicy foods
-What happens when the client eats spicy foods
-Which spicy foods cause a problem
-How often does the client eats spicy foods

-What happens when the client eats spicy foods
After completing the client interview, where Calvin reports that he gets severe indigestion and heartburn after eating Mexican foods, the R is ready to begin the physical assessment of the abdomen

5. The RN prepares calvin for the physical assessment of the abdomen. Before assisting him to a supine position, what action should the RN take? (select all that apply)

-Ask the Client to breathe deeply several times
-Put on the room lights and ensure that the room temperature is comfortable
-Encourage the client to empty his bladder
-Instruct the client to place his hands over his head.

-Put on the room lights and ensure that the room temperature is comfortable

-Encourage the client to empty his bladder

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After completing the preparations, the RN assists Calvin to a supine position on the bed.

6. To assess the symmetry of the abdomen, what action should the nurse take?
-Inspect for masses or bulges
-Check for an aortic pulsation
-Note pattern of hair growth
-Observe for any visible peristalsis

-Inspect for masses of bulges
The assessment reveals that the Client’s abdomen is symmetrical, with no masses or bulges observed.

7. The RN does not observe any pulsation of the abdominal aorta. The RN recognizes that this is consistent with what other assessment finding?

-Depressed umbilicus
-Abdominal movement with respirations
-Protuberant abdominal contour
-Dark brown skin pigmentation

-Protuberant abdominal contour
While inspecting Calvin’s abdomen, the RN observes silvery while striae on the lower abdomen. In response to this finding, what information should the nurse obtain? (select all that apply.
-Any recent exposure to sunlight
-Previous trauma or injury to the area
-Date of last bowel movement
-Change in body mass index (BMI)
-Past medical history of ascites
-Change in body mass index (BMI)
-Past medical history of ascites
After inspecting the abdomen, the RN prepares to assess the client’s bowel sounds.

9. To ensure the most accurate assessment of peristalsis, what action should the nurse RN take? (Place in order from first action through last action).
-inspection
-percussion
-auscultation
-palpation

Inspection
Auscultation
Percussion
Palpation
The RN first listens for bowel sounds in the right lower quadrant (RLQ). The RN hears high-pitched gurgling sounds that occur irregularly.

10. What action should the RN take next?
-Move to the left lower quadrant (LLQ) to hear sounds more distinctly
-Continue to listen over the RLW until a regular pattern of sounds is heard
-Listen for 5 minutes before documenting the activity of the bowel sounds
-Note how frequently the sounds occur before moving to another quadrant

-Note how frequently the sounds occur before moving to another quadrant
11. It is essential for the RN to listen for bowel sounds in which area(s)? (select all that apply).
-Epigastric area
-Right upper and lower quadrants
-Umbilical area
-Left quadrants
-Right quadrants
-Right upper and lower quadrants
-Left quadrants
-Right quadrants
The RN listens in all areas and hears gurgling sounds at each location and hears between 8 and -20 sounds per minute.

12. How should the nurse document the assessment?
-Borborygmus present
-Hypoactive bowel sounds
-Hyperactive bowel sounds
-Normal Bowel sounds

Normal Bowel Sounds
After auscultating the client’s bowel sounds, the RN also listens for abdominal vascular sounds but does not hear any sounds.

13. What action should the RN take in response to this finding? (select all that apply)
-Plan to notify the healthcare provider(HCP) after completing the assessment
-continue to monitor
-document this normal finding on the client’s assessment record.
-Stop the abdominal assessment and measure the client’s vital signs.

Document this normal finding on the client’s assessment record.

continue to monitor

After completing auscultation of the client’s abdomen, the RN prepares to percuss Calvin’s abdomen.

14. A dull sound is heard when the RN percusses over the suprapubic area. What action should the RN take in response to this finding?
-Assist the client to a sitting position immediately
-Ask the client to breathe deeply and percuss again.
-Determine if the client feels bloated or gaseous
-Observe the area for bladder distention

observe the area for bladder distention
While percussing the abdomen, the RN hears tympany over most of the abdomen but notes a duller sound when percussing at the right costal margin.

15. What follow-up action should the RN take?
-Document the presence of splenic dullness
-Review the client’s medical history
-Note this location as the border of the liver
-auscultate for adventitious breath sounds

Note this location as the border of the liver
16. The RN’s goal in palpating the client’s abdomen is to screen for any masses or tenderness. To achieve this goal, what action should the RN take first?
-Lightly palpate the abdominal surface
-Gently palpate the edges of the liver
-Carefully palpate areas of tenderness
-Deeply palpate each abdominal organ
lightly palpate the abdominal surface
When beginning palpation of the client’s abdomen, the RN uses a circular finger motion to depress the client’s skin about a half centimeter. While palpating, the RN observes that the client’s superficial abdominal muscles are tensing bilaterally.

17. What action should the RN take?
-Decrease the amount of pressure applied
-Document the onset of rebound tenderness
-Observe the muscles while the client exhales
-Stop any further palpation immediately

-Observe the muscles while the client exhales
After palpating Calvin’s abdomen, the RN observes that Calvin is very fatigued. He states that the nausea medication has made him very sleepy. The RN concludes the assessment to allow Calvin to rest.

18. Which information is most important to report to the RN assuming responsibility for Calvin’s care?
-The time the client received an antiemetic
-The client’s intolerance of spicy foods
-The client’s recent history of weight loss
-The presence of striae on the client’s abdomen

-the time the client received an antiemetic
19. During the report, the RN also describes the client’s earlier emesis. The RN should describe the emesis in terms for which characteristics?
-Dyspepsia and anorexia
-Turgor and moisture
-Intensity and quality
-Color and Volume
color and volume
Three hours later, Calvin’s wife calls the RN, stating that he seems to be experiencing increasing abdominal pain.

The RN ask Calvin where he is experiencing pain. He points to his right lower abdomen.

20. When completing the pain assessment, how should the RN assess for rebound tenderness?
-lightly palpate over the painful area
-ask the client to describe the pain
-position the client on his right side
-push down on the left side of the abdomen

push down on the left side of the abdomen
21. After observing the presence of rebound tenderness, the RN notes the onset of involuntary rigidity of the client’s abdomen. Which action should the nurse implement?

-Place a warm moist pack on the client’s abdomen
-Guide the client through relaxation exercises
-Assist the client to a semi-fowler’s position
-Notify the healthcare provider of the findings

Notify the healthcare provider of the findings
After the RN reports the findings to the healthcare provider, Calvin is scheduled for immediate surgery. Following surgery, Calvin returns to his room. During the nursing assessment on the first postoperative day, Calvin seems anxious and tells the RN that he “hurts a lot”.

22. In response to the client’s statement that he “hurt’s a lot,” what action should the RN take first?

-Assess the client’s vital signs and oxygen saturation
-Ask the client where he is experiencing the pain
-Determine when the client last received an analgesic
-Observe the appearance of the surgical incision

Ask the client where he is experiencing the pain
23. After completing the pain assessment, the RN prepares to administer a prescribed opioid analgesic. Hydrocodone 10mg by mouth every 6 hours is prescribed. Hydrocodone 5 mg per tablet is available. How many tablets should the RN administer? _____________ (enter numerical value only)
2
Thirty minutes later, the RN returns to the client’s room to assess Calvin’s response to the medication.

24. Which finding provides the most useful data about the effectiveness of the medication?
-The client’s facial expression is calm and relaxed
-The client’s vital signs are within normal limits
-The client is holding a pillow over his abdomen
-The client denies any lessening of his pain

The client denies any lessening of his pain.
25. To learn about the intensity of the client’s pain, what action should the RN take?
-Determine what actions the client has already taken to reduce his pain
-Ask the client how well he normally tolerates daily aches and pains
-Encourage the client to use a numeric pain scale to rate his pain
-Question the client about how the pain limits his ability to function
-Encourage the client to use a numeric pain scale to rate his pain
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