HESI Abdominal Assessment Case Study

Thirty minutes later, the nurse returns to assess the client's response to the medication. Which findings provide the best data about the effectiveness of the medication? (Select all that apply.)

The client's vital signs are within normal limits. The client's vital signs (within normal limits) provide useful data about the client's response to pain. The client's facial expression is calm and relaxed. The client's nonverbal behavior can provide valuable data about her response to pain, and it is a useful source of information about the effectiveness of an analgesic. The client states a lessening of her pain. The client's subjective report regarding her pain is important information for the nurse to assess when evaluating the effectiveness of analgesic administration.

The nurse assesses the patient's vomitus. Which finding would the nurse be the most concerned about?

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.

What action should the nurse take?

Use the client's own hand to assist with palpation. The nurse will place their hand over the client's hand and fingers. People are not ticklish to themselves.

A dull sound is heard when the nurse percusses over the suprapubic area. What action should the nurse take in response to this finding?

Observe the area for bladder distention. A dull sound upon percussion may be heard over a distended bladder.

The nurse is completing an inspection of the abdomen. Which findings would cue the nurse of the need for action? Select all that apply

A protruberant shaped abdomen. A protruberant shaped abdomen indicates abdominal distention. Marked visible peristalsis. Visible peristalsis may be seen in very thin people. Especially in the presence of a protruberant abdomen may indicate a bowl obstruction and would require the nurse to follow up.

In response to the client's statement that she is in a lot of pain, what action should the nurse take first?

Ask the client to describe her pain location and intensity. The nurse should begin by gathering further data about the pain, including location, intensity, and quality.

What questions should the nurse ask next? (Select all that apply.)

Can you identify which spicy foods cause a problem? This information will be helpful in planning interventions for meal preparation What happens when you eat spicy foods? The client's response is the most useful regarding the nature of her inability to eat spicy foods and any underlying problems.

Based on the client's assessment, what condition would the nurse suspect?

Cholecystitis Characterized by right upper quadrant pain, nausea, and vomiting after eating.

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. It is important for the nurse to describe the appearance of the emesis, which includes the color. Vomit without odor. It is important for the nurse to describe any odor of the emesis, which could indicate the presence of blood, undigested foods, or fecal contaminant. Approximately 250ml of vomit was noted. It is important for the nurse to describe the volume or amount of emesis. Client vomited x 1 lasting approximately 2 minutes. The duration will describe if the episodes of vomiting were short, sporadic, ongoing, or intermittent.

What action should the nurse take next?

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.

Management of Care Which assessment should the nurse complete first?

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.

Which assessment takes priority while the nurse provides oral care?

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.

Pharmacological and Parenteral TherapiesAfter completing the pain assessment, the nurse prepares to administer a prescribed opioid analgesic: Morphine Sulfate 6 mg by intravenous push every 6 hours. Morphine is available in 10 mg/1 mL vials. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the tenth.)

Desired dose divided by Dose on hand = Dose to give 6mg/10 mg /1 ml = 0.6 mL

What additional focused interview questions will be important for the nurse to ask the client?

Do you have a history of any abdominal conditions or surgeries? Important to establish baseline of what has occurred in the client's past. Have you experienced any weight gain or weight loss? Weight gain or loss can be indicative of more complex GI problems or a side effect of certain medications.

For the nurse to learn about the client's bowel patterns, which questions are most important to ask the client? (Select all that apply.)

Do you take any prescription or over-the-counter medications? Medications can cause adverse GI effects. Assess for presence of laxatives, stool softeners, or antidiarrheal medications. Have you had any changes in your bowel movements? Changes in bowel habits can be due to various etiologies, such as diet, stress, activity, and medications. What is the color and consistency of your bowel movements? Black or red stools can indicate the presence of bleeding in the GI system. Establishing a baseline of what a normal for the client is important for further assessment. How often do you have a bowel movement? This information is an important part of the client's history. It establishes a baseline for assessment purposes.

What action should the nurse take in response to this finding?

Document this normal finding on the client's assessment record. Abdominal vascular sounds are not normally heard, so the only action necessary is to record this normal finding on the assessment record.

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. Emptying the bladder will help promote relaxation of the abdominal wall. Place a pillow under the client's knees. Placing a pillow under the client's knees promotes relaxation of the abdominal muscles. Inquire where the client is experiencing pain. This guides the nurse with the examination during percussion and palpation. Quadrants with pain are examined last due to muscle guarding. Discuss the sequence of steps performed during the abdominal assessment. Telling the client what to expect during a procedure helps promote relaxation.

When continuing to assess the abdominal area, the nurse hears a swishing sound. In what area would this sound be heard?

Femoral artery. This area would produce a swishing sound that occurs during systole (vascular sounds).

To ensure the most accurate assessment of the abdomen, what actions should the nurse take? (Place in order from first action through last action.)

Inspection Auscultation Percussion Palpation The correct order of the assessment is inspection, auscultation, percussion, and palpation. Percussion and palpation of the abdomen may stimulate peristalsis, so inspection and then auscultation should be completed first to ensure an accurate assessment of peristalsis.

The nurse's goal in palpating the client's abdomen is to screen for any masses or tenderness. To achieve this goal, what action should the nurse take first?

Lightly palpate the abdominal surface. Light palpation allows the nurse to screen the abdomen for any obvious masses or tenderness before applying deeper palpation that may cause pain or rigidity.

What further assessment technique would the nurse consider to confirm a problem with the gallbladder?

Murphy's sign Pain is elicited when gallbladder inflammation is present.

Which is the most appropriate follow up action the nurse should implement? (Select all that apply.)

Note this location as the border of the liver. Dullness upon percussion is generally heard over organs, such as the liver. The right costal margin is the location at which the abdominal tympany should change to dullness over the liver border. This location is useful in determining liver span. Document the finding as normal. The right costal margin is the location at which the abdominal tympany should change to dullness over the liver border.

After observing the presence of rebound tenderness, the nurse notes the onset of involuntary rigidity of the client's abdomen. Which action should the nurse implement?

Notify the HCP of the findings. Rebound tenderness and involuntary rigidity (guarding) are abnormal findings associated with peritoneal irritation and are signs that should be reported to the HCP immediately for further diagnostic evaluation.

To learn about the intensity of the client's pain, what pain scale is most appropriate to use to assess the client's pain?

Numeric pain scale A numeric pain scale is an effective tool for measuring pain intensity.

What statements from the client's focused interview correlate to the abnormal inspection findings? (Select all that apply.)

Past surgical history of an appendectomy. Appendectomy scars will usually be present in the right lower quadrant. Change in body mass index (BMI). 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 obesity or pregnancy.

The nurse is assessing for costo-vertebral angle (CVA) tenderness. Which statements best describe this percussion assessment? (Select all that apply.)

Percussion is completed over the 12th rib in the back bilaterally. Correct, Percussion is completed over the 12th rib at the CVA angle in the back bilaterally. Place one hand over the flank area and hit the hand with the ulnar side of the fist. The technique is used to assess for inflammation of the kidney. Correct, pain elicited during this technique may indicate inflammation of the kidney.

When completing the pain assessment, how should the nurse assess for rebound tenderness?

Push down on the left side of the abdomen. After applying pressure at a site away from the area of pain, the nurse quickly lifts and removes the hand from the client's abdomen. Pain upon release of the pressure is referred to as rebound tenderness.

Determine the correct sequence for auscultation of the client's abdomen. (Place in order from first to last.)

RLQ LLQ LUQ RUQ Begin assessment in the right lower quadrant due to the presence of the ileocecal valve area because bowel sounds normally are present there. The right upper quadrant will be done last due to the presence of pain. To maintain a systematic approach, the left lower quadrant should be done second followed by the left upper quadrant.