HESI abdominal assessment case study – Flashcards

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