HESI Case Study- Abdominal Flashcards
The client is a female, mature adult who was admitted to the medical/surgical unit with complaints of right upper quadarant abdominal pain, nausea and vomiting for the last 3 hours. Client rates her pain 5/10. Vital signs include heart rate 92 beats/minute, respirations 20 breaths/minute, and blood pressure 132/70 mmHg. The client is accompanied by her spouse.
Which assessment should the nurse complete first?
Check the pulse.
Listen to bowel sounds.
Observe the color of the emesis.
Obtain a STAT blood pressure.
Observe the color of the emesis.
Since the client is vomiting, the nurse should first observe the color and appearance of the emesis for any obvious bleeding or other indications of risk to the client’s homeostasis.
The nurse assesses the patient’s vomitus. Which finding would the nurse be the most concerned about?
Green vomit with particles of food.
Thick dark brown vomit
White foamy vomit
Yellow clear vomit
Thick dark brown vomit
Thick dark brown vomit may indicate the presents of stool or blood. This is an abnormal finding that would need to be investigated and communicated.
The nurse is documenting the client’s vomitus. Which documentation should be included in the client’s medical record? (Select all that apply.)
Client vomited green with undigested food particles.
Vomit without odor.
Vomit is soft in consistency.
Approximately 250ml of vomit was noted.
Client vomited x 1 lasting approximately 2 minutes.
Client vomited green with undigested food particles.
Vomit without odor.
Approximately 250ml of vomit was noted.
Client vomited x 1 lasting approximately 2 minutes.
The client vomits 200 milliliters of yellow-green liquid. The client continues to feel nauseated. The nurse administers a PRN dose of a prescribed antiemetic. Shortly after the nurse administers the antiemetic, the client states she feels better. The nurse offers to provide oral care with a mint-flavored foam swab and cool water.
Which assessment takes priority while the nurse provides oral care?
Assess for presence of dentures.
Observe the condition of the mucus membranes.
Evaluate the color of the gums
Check for the presence of cavities.
Observe the condition of the mucus membranes.
Because the client has a recent history of nausea, vomiting, and weight loss, the RN should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness.
Fifteen minutes after receiving the antiemetic, the client stops vomiting, appears relaxed, and denies further nausea. She states that she is comfortable enough for the nurse to begin the admission assessment.
The nurse questions the client about what brought her to the hospital. The client states she had right upper quadrant abdominal pain, nausea and vomiting right after she ate lunch. Pain remains at 5/10. The client states her last bowel movement was yesterday.
For the nurse to learn about the client’s bowel patterns, which questions are most important to ask the client? (Select all that apply.)
Have you had any recent onset of heartburn?
Do you take any prescription or over-the-counter medications?
Have you had any changes in your bowel movements?
What is the color and consistency of your bowel movements?
How often do you have a bowel movement?
Do you take any prescription or over-the-counter medications?
Have you had any changes in your bowel movements?
What is the color and consistency of your bowel movements?
How often do you have a bowel movement?
The nurse questions the client if there are any foods she cannot eat. The client reports that she doesn’t tolerate spicy foods.
What questions should the nurse ask next? (Select all that apply.)
Can you identify which spicy foods cause a problem?
How often do you eat spicy foods?
What happens when you eat spicy foods?
Does anyone in your family have problems with spicy food?
Why do you think spicy foods are a problem?
Can you identify which spicy foods cause a problem?
What happens when you eat spicy foods?
What additional focused interview questions will be important for the nurse to ask the client?
Select all that apply
Do you have a history of any abdominal conditions or surgeries?
Have you experienced any weight gain or weight loss?
Are you have any difficulty with urination?
Are you experiencing any shortness of breath?
Do you have any difficulty swallowing your food?
Do you have a history of any abdominal conditions or surgeries?
Have you experienced any weight gain or weight loss?
After completing the client interview, the nurse is ready to begin the physical assessment of the abdomen.
The nurse prepares the client for the physical assessment of the abdomen. What actions should the nurse take prior to initiating the assessment? (Select all that apply.)
Encourage the client to empty her bladder.
Place a pillow under the client’s knees.
Inquire where the client is experiencing pain.
Instruct the client to place her hands over her head.
Discuss the sequence of steps performed during the abdominal assessment.
Encourage the client to empty her bladder.
Place a pillow under the client’s knees.
Inquire where the client is experiencing pain.
Discuss the sequence of steps performed during the abdominal assessment.
To ensure the most accurate assessment of the abdomen, what actions should the nurse take? (Place in order from first action through last action.)
1. Auscultation.
2. Inspection.
3. Palpation.
4. Percussion.
1.Inspection.
2.Auscultation.
3.Percussion.
4.Palpation.
The nurse is completing an inspection of the abdomen. Which findings would cue the nurse of the need for action?
Select all that apply
The presence of striae on the right and left lower quadrants.
A protruberant shaped abdomen.
A midline, inverted umbilicus.
A large amount of pigmented nevi scattered accross the abdomen.
Marked visible peristalsis.
A protruberant shaped abdomen.
Marked visible peristalsis.
While inspecting the client’s abdomen, the nurse notes the following: Abdomen is rounded and symmetrical. No bulges or masses seen. Umbilicus is inverted and midline. No rashes noted. Silvery white striae noted on the lower abdomen. A four centimeter scar is noted on the right lower quadrant of the abdomen. No visible pulsations or perstalsis noted. No hair noted.
What statements from the client’s focused interview correlate to the abnormal inspection findings? (Select all that apply.)
Daily bowel movements
Past surgical history of an appendectomy.
Nausea and vomiting.
Food intolerance to spicy foods.
Change in body mass index (BMI).
Past surgical history of an appendectomy.
Change in body mass index (BMI).
Where should the nurse begin abdominal auscultation?
They can begin anywhere.
Right upper quadrant (RUQ).
Right lower quadrant (RLQ)
Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Place the stethoscope lightly on the abdominal wall, beginning in the RLQ in the area of the ileocecal valve, where bowel sounds are normally present. Proceed with listening to other quadrants in a systemic manner.
The nurse auscultates the client’s abdomen. The nurse notes eight high-pitched gurgling sounds occurring at irregular intervals in the right lower abdomen over 15 seconds.
What action should the nurse take next?
Move to the right upper quadrant (RUQ) to hear the sounds more distinctly.
Continue to auscultate for bowel sounds in the right lower quadrant.
Change to the bell of the stethoscope to listen.
Listen for 5 minutes before documenting the activity of the bowel sounds.
Continue to auscultate for bowel sounds in the right lower quadrant.
The pattern of bowel sounds is typically irregular and the duration of bowel sounds may range from 1 second to several seconds. Expected amount of bowel sounds is between 8-30 over 1 minute. Need to assess if bowel sounds are hypoactive, hyperactive, or normal.
When continuing to assess the abdominal area, the nurse hears a swishing sound. In what area would this sound be heard?
Femoral artery.
Epigastric area.
Umbilical area.
Right quadrants.
Femoral artery.
The nurse listens in all areas and hears gurgling sounds at each location between 8 to 20 sounds per minute. After auscultating the client’s bowel sounds, the nurse also listens for abdominal vascular sounds, which are soft, low-pitched, and continuous. The nurse does not hear any venous sounds.
What action should the nurse take in response to this finding?
Stop the assessment and notify the healthcare provider (HCP) immediately of the assessment finding.
Take the client’s blood pressure and heart rate after the assessment.
Call another nurse to verify the finding.
Document this normal finding on the client’s assessment record.
Document this normal finding on the client’s assessment record.
