HESI abdominal assessment case study – Flashcards
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Observe the color of the emesis.
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Which assessment should the RN complete first?
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Observe for excessive dryness of the mucus membranes.
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Which assessment takes priority while the RN provides oral care?
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Any difficulty with defecation.
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For the RN to learn about the client's bowel patterns, what information is most important to obtain from Mr. Dunner?
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What happens when the client eats spicy foods.
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The nurse asks Calvin if there are any foods he cannot eat. He reports that he can't eat spicy foods. What information should the nurse obtain next?
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Put on the room lights and ensure that the room temperature is comfortable. Encourage the client to empty his bladder.
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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.)
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Inspect for masses or bulges.
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To assess the symmetry of the abdomen, what action should the nurse take?
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Protuberant abdominal contour.
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The RN does not observe any pulsations of the abdominal aorta. The RN recognizes that this is consistent with what other assessment finding?
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Past medical history of ascites. Change in body mass index (BMI).
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While inspecting Calvin's abdomen, the RN observes silvery white striae on the lower abdomen. In response to this finding, what information should the nurse obtain? (Select all that apply.)
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Inspection Auscultation Percussion Palpation
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To ensure the most accurate assessment of peristalsis, what action should the nurse RN take? (Place in order from first action through last action.)
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Note how frequently the sounds occur before moving to another quadrant.
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What action should the RN take next?
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Left quadrants. Right quadrants. Right upper and lower quadrants.
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It is essential for the RN to listen for bowel sounds in which area(s)? (Select all that apply.)
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Normal bowel sounds.
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How should the nurse document the assessment?
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Document this normal finding on the client's assessment record. continue to monitor
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What action should the RN take in response to this finding? (Select all that apply.)
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Observe the area for bladder distention.
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A dull sound is heard when the RN percusses over the suprapubic area. What action should the RN take in response to this finding?
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Note this location as the border of the liver.
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What follow-up action should the RN take?
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Lightly palpate the abdominal surface.
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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?
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Observe the muscles while the client exhales.
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What action should the RN take?
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The time the client received an antiemetic.
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Which information is most important to report to the RN assuming responsibility for Calvin's care?
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Color and volume.
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During the report, the RN also describes the clients earlier emesis. The RN should describe the emesis in terms of which characteristics?
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Push down on the left side of the abdomen.
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When completing the pain assessment, how should the RN assess for rebound tenderness?
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Notify the healthcare provider of the findings.
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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.
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Ask the client where he is experiencing pain.
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In response to the client's statement that he "hurts a lot," what action should the RN take first?
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22
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After completing the pain assessment, the RN prepare to administer a prescribed opioid analgesic. Hydrocodone 10 mg by mouth every 6 hours is prescribed. Hydrocodone 5 mg tablet is available. How many tablets should the RN administer?
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The client denies any lessening of his pain.
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Which finding provides the most useful data about the effectiveness of the medication?
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Encourage the client to use a numeric pain scale to rate his pain.
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To learn about the intensity of the client's pain, what action should the RN take?
