History

In which order would the nurse perform a gastrointestinal assessment for a patient who presents with abdominal pain and vomiting? Take a focused patient history Auscultate Ask the patient to empty his or her bladder Inspect Palpate Percuss

Take a focused patient history Ask the patient to empty his or her bladder Inspect Auscultate Percuss Palpate Before performing a gastrointestinal assessment, the nurse would take a focused history. Then, the nurse would ask the patient to empty his or her bladder and assist the patient into a supine position. The order of the assessment is inspection, auscultation, percussion, and then palpation.

Which question would the nurse ask the patient when assessing for acute pancreatitis? "How often do you drink alcohol?" "Have you experienced diarrhea?" "Have you increased your NSAID consumption?" "How often do you take nutritional supplements?"

"How often do you drink alcohol?" Acute pancreatitis is associated with a history of cholelithiasis or excessive alcohol use.

Match the condition to the corresponding abdominal auscultation assessment finding. 1. Tinkling hyperactive bowel sounds 2. Gurgling sounds every 30 seconds 3. Absence of bowel sounds a. Peritoneal irritation b. Diarrhea c. Ischemia

1. b 2. a 3. c

Match the gastrointestinal disorder with the corresponding assessment findings. 1. Tenderness in right lower quadrant, rebound tenderness 2. Positive Murphy sign, tenderness in right upper quadrant 3. Rebound tenderness, limited diaphragmatic excursion of lungs a. Cholelithiasis b. Acute pancreatitis c. Obstruction d. Peptic ulcer perforation e. Appendicitis

1. e 2. a 3. b

Match the anatomic correlate of the abdomen to the location in which it is found. 1. Right upper 2. Left upper 3. Right lower 4. Midline a. Appendix b. Spleen c. Sigmoid colon d. Aorta e. Gallbladder

1. e 2. b 3. a 4. d

How deep would the nurse palpate when assessing a patient for the presence of an abdominal mass? 1 cm 2 cm 3 cm 4 cm

4 cm Deep palpation, which is done at the depth of about 4 cm, is used to assess for abdominal masses.

A patient presents to the emergency department with a sudden onset of severe, intense, steady epigastric pain. The nurse anticipates that which diagnostic study will be performed? Abdominal x-ray Complete blood count Serum amylase level Contrast enema study

Abdominal x-ray Sudden intense epigastric pain indicates a perforated ulcer, which would be assessed used abdominal x-rays.

A patient presents with hyperactive, tinkling bowel sounds and a sudden onset of abdominal cramping. Which question would the nurse ask the patient during the history? Is your pain worse with coughing? Does the pain radiate to your right shoulder? Have you consumed a lot of NSAIDs recently? Have you experienced any vomiting or diarrhea?

Have you experienced any vomiting or diarrhea? Hyperactive bowel sounds indicate a bowel obstruction, which also causes vomiting and/or diarrhea.

When taking the history of a patient admitted with gastrointestinal problems, which question would the nurse ask to assess the patient's lifestyle? Select all that apply. One, some, or all responses may be correct. How much fluid do you usually drink daily? Do you take any vitamins or nutritional supplements? How often do you have bowel movements? Have you had any abdominal surgeries? Are you experiencing dysphagia or oral lesions?

How much fluid do you usually drink daily? The nurse would assess the usual fluid intake per day and other dietary habits. Do you take any vitamins or nutritional supplements? The nurse would assess the type, amount, and frequency for vitamins and nutritional supplements. How often do you have bowel movements? It is important for the nurse to assess usual bowel elimination information, such as frequency, consistency, and color.

While inspecting a patient's oral cavity as part of a gastrointestinal assessment, the nurse would observe for which abnormal finding? Select all that apply. One, some, or all responses may be correct. Inflammation of gums Presence of dental caries Missing teeth Ill-fitting dentures Ability to taste

Inflammation of gums Inflammation of gums can lead to soreness and difficulty swallowing or chewing food. Presence of dental caries Significant dental caries can affect nutrition due to the inability to chew and swallow food. Missing teeth Missing teeth alters the ability to consume food and impairs nutrition. Ill-fitting dentures Ill-fitting dentures alter the ability to consume food, which impairs nutrition.

Which action would the nurse take when performing abdominal auscultation? Assist the patient to a semi-Fowler's position. Listen with the bell of the stethoscope. Initially listen below and to the right of the umbilicus. Wait 5 minutes before moving to the next quadrant.

Initially listen below and to the right of the umbilicus. The first step the nurse would take is to listen below and to the right of the umbilicus with the diaphragm of the stethoscope.

The nurse would auscultate which quadrant when assessing for a bowel obstruction within the sigmoid colon? Left upper quadrant Left lower quadrant Right upper quadrant Right lower quadrant

Left lower quadrant The sigmoid colon is in the left lower quadrant, so that is the area the nurse would auscultate when assessing for a bowel obstruction.

The nurse is performing a gastrointestinal assessment for a patient with mononucleosis. In which quadrant would the nurse assess for tenderness and inflammation? Right upper Left lower Left upper Right lower

Left upper Mononucleosis causes inflammation and pain in the spleen, which is located in the left upper quadrant.

Percussion is used to assess which gastrointestinal organ? Select all that apply. One, some, or all responses may be correct. Liver Spleen Pancreas Stomach Colon

Liver Percussion is used to assess the deep organs, such as the liver. Spleen Percussion is used to assess the deep organs, such as the spleen. Pancreas Percussion is used to assess the deep organs, such as the pancreas.

The nurse auscultates a patient's abdomen and notes that, in every quadrant, bowel sounds occur every 20 seconds. The nurse suspects which GI disorder? Peritonitis Pancreatitis Cholelithiasis Gastroenteritis

Peritonitis Bowel sounds that occur every 20 seconds are considered to be hypoactive. (Normal bowel sounds occur every 5 to 10 seconds.) Hypoactive bowel sounds may indicate peritonitis.

A patient admitted for abdominal pain and vomiting has tenderness on palpation and experiences a sudden increase in pain when the nurse quickly releases the area being palpated. Based on the assessment findings, the nurse suspects which GI disorder? Hepatitis Gastritis Peritonitis Constipation

Peritonitis Rebound tenderness, or sharp pain with release of pressure/palpation, indicates inflammation of the peritoneum.

Which assessment finding might the nurse document when completing the inspection of a patient's abdomen? Select all that apply. One, some, or all responses may be correct. Significant striae on abdomen Everted umbilicus with distention Tenderness in lower left quadrant Enlarged liver in upper right quadrant Rebound tenderness

Significant striae on abdomen The nurse would assess for the presence of striae (stretch marks) on the abdomen. Everted umbilicus with distention Abdominal distention can sometimes cause an everted umbilicus, which would be noted during inspection.

Label the areas where the nurse would assess for the presence of bruits. 1 Aorta 2 Left femoral artery 3 Left iliac artery 4 Left renal artery 5 Right femoral artery 6 Right iliac artery 7 Right renal artery

Starting at the RLQ (their right) and moving clockwise: 5 6 7 1 4 3 2