Abdominal Assessment

Question 1

Meet the Client: Mr. Calvin Dunner
Mr. Calvin Dunner is a 38-year-old African-American male admitted to the Acute Care facility from the Emergency Department with a recent history of weight loss, nausea, and vomiting. He is NPO and is scheduled for diagnostic tests the next morning.

Answer 1

Info

Question 2

Mr. Dunner is admitted to his room accompanied by his wife. Before the nurse can begin the admission assessment, Mr. Dunner states that he needs to “throw up.” The nurse helps him sit up and provides an emesis basin.

Mr. Dunner vomits into the emesis basin and then remains sitting on the side of the bed, stating he may need to “throw up” again.
1.
Which assessment should the nurse complete first?
Auscultate the bowel sounds.
Palpate for abdominal distention.
Observe the color of the emesis.
Ask about recent loss of appetite.

Answer 2

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.

Question 3

Mr. Dunner continues to feel nauseated. Mrs. Dunner remains with her husband while the nurse leaves the room to prepare a PRN dose of a prescribed antiemetic.

Shortly after the nurse administers the antiemetic, Mr. Dunner states he feels “better.” The nurse offers to provide oral care with a mint-flavored foam swab and cool water.
2.
Which assessment takes priority while the nurse provides oral care?
Assess the sides of the oral cavity for any open sores.
Observe for excessive dryness of the mucus membranes.
Palpate the salivary glands for tenderness or swelling.
Check for deviation when the client sticks out his tongue.

Answer 3

Observe for excessive dryness of the mucus membranes.
Because the client has a recent history of nausea, vomiting, and weight loss, the nurse should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness.

Question 4

Fifteen minutes after receiving the antiemetic, Mr. Dunner has stopped vomiting, appears relaxed, and denies further nausea. He states he is comfortable enough for the nurse to begin the admission assessment and asks the nurse to call him Calvin.
3.
The nurse begins the client interview, focusing on the gastrointestinal system. To learn about the client’s bowel patterns, what information is most important to obtain from Mr. Dunner?
Recent onset of flatulence.
Presence of abdominal distention.
Amount of fiber in the diet.
Any difficulty with defecation.

Answer 4

Any difficulty with defecation.
To fully assess the client’s bowel patterns, it is essential to obtain information related to any difficulty with defecation, such as straining or pain.

Question 5

The nurse asks Calvin if there are any foods he cannot eat. He reports that he can’t eat spicy foods.
4.
What information should the nurse obtain next?
Which spicy foods cause a problem.
How often does the client eats spicy foods.
What happens when the client eats spicy foods.
When does the client develop his intolerance to spicy foods.

Answer 5

What happens when the client eats spicy foods.
The client’s response is the most useful information regarding the nature of his inability to eat spicy foods and any underlying problems.

Question 6

Physical Assessment: Inspection

After completing the client interview, where Calvin reports that he gets severe indigestion and heartburn after eating Mexican foods, the nurse is ready to begin the physical assessment of the abdomen.
5.
The nurse prepares Calvin for the physical assessment of the abdomen. Before assisting him to a supine position, what action should the nurse take?
Encourage the client to empty his bladder.
Ask the client to breathe deeply several times.
Darken the room lights and lower the thermostat.
Instruct the client to place his hands over his head.

Answer 6

Encourage the client to empty his bladder.

Emptying the bladder will help promote relaxation of the abdominal wall.

Question 7

After completing the preparations, the nurse assists Calvin to a supine position on the bed.
6.
To assess the symmetry of the abdomen, what action should the nurse take?
Note pattern of hair growth.
Check for an aortic pulsation.
Observe for any visible peristalsis.
Inspect for masses or bulges.

Answer 7

Inspect for masses or bulges.

The presence of masses or bulges will alter the symmetry of the abdomen, resulting in an asymmetric shape.

Question 8

The assessment reveals that the client’s abdomen is symmetrical, with no masses or bulges observed.
7.
The nurse does not observe any pulsation of the abdominal aorta. The nurse recognizes that this is consistent with what other assessment finding?
Depressed umbilicus.
Protuberant abdominal contour.
Dark brown skin pigmentation.
Abdominal movement with respirations.

Answer 8

Protuberant abdominal contour.
Pulsation of the abdominal aorta may be observed in persons with a small or average build, but it is often not visible in heavy individuals or those with a distended or protuberant abdomen.

Question 9

8.
While inspecting Calvin’s abdomen, the nurse observes silvery white striae on the lower abdomen. In response to this finding, what information should the nurse obtain? (Select all that apply.)
  Date of last bowel movement.
  Past medical history of ascites.
  Any recent exposure to sunlight.
  Previous trauma or injury to the area.
  Change in body mass index (BMI).

Answer 9

Past medical history of ascites.
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 ascites (fluid collection in the peritoneal cavity).

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.
Calvin proudly tells the nurse that, although he is still overweight, he has lost more than 100 pounds in the last 2 years.

Question 10

Physical Assessment: Auscultation

After inspecting the abdomen, the nurse prepares to assess the client’s bowel sounds.
9.
To ensure the most accurate assessment of peristalsis, what action should the nurse take?
Firmly compress the abdomen with the diaphragm of the stethoscope.
Palpate for distention before determining placement of the stethoscope.
Complete auscultation before percussion and palpation of the abdomen.
Place the bell of the stethoscope lightly over the midline of the abdomen.

Answer 10

Complete auscultation before percussion and palpation of the abdomen.
Percussion and palpation of the abdomen may stimulate peristalsis, so auscultation should be completed first to ensure an accurate assessment of peristalsis.

Question 11

Physical Assessment: Auscultation

The nurse first listens for bowel sounds in the right lower quadrant (RLQ). The nurse hears high-pitched gurgling sounds that occur irregularly.
10.
What action should the nurse take next?
Move to the left lower quadrant (LLQ) to hear the sounds more distinctly.
Continue to listen over the RLQ until a regular pattern of sounds is heard.
Note how frequently the sounds occur before moving to another quadrant.
Listen for 5 minutes before documenting the activity of the bowel sounds.

Answer 11

Note how frequently the sounds occur before moving to another quadrant.
The nurse should determine the frequency of the bowel sounds before continuing the assessment in another quadrant.

Question 12

11.
It is essential for the nurse to listen for bowel sounds in which area(s)? (Select all that apply.)
  Aortic area.
  Epigastric area.
  Umbilical area.
  Right quadrants.
  Left quadrants.

Answer 12

Right quadrants.
The nurse should systematically listen for bowel sounds in the four quadrants of the abdomen, which include the right upper and lower quadrants.

Left quadrants.
The nurse should systematically listen for bowel sounds in the four quadrants of the abdomen, which include the left upper and lower quadrants.

Question 13

The nurse listens in all areas and hears gurgling sounds at each location. The nurse hears anywhere from 8 – 20 sounds per minute.
12.
How should the nurse document the assessment?
Normal bowel sounds.
Hypoactive bowel sounds.
Hyperactive bowel sounds.
Borborygmus present.

Answer 13

Normal bowel sounds.

Normal bowel sounds occur irregularly, approximately 5 to 30 times per minute.

Question 14

After auscultating the client’s bowel sounds, the nurse also listens for abdominal vascular sounds but does not hear any sounds.
13.
What action should the nurse take in response to this finding?
Plan to notify the healthcare provider after completing the assessment.
Stop the abdominal assessment and measure the client’s vital signs.
Lightly palpate over the vascular areas for the presence of a thrill.
Document this normal finding on the client’s assessment record.

Answer 14

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.

Question 15

Physical Assessment: Percussion

After completing auscultation of the client’s abdomen, the nurse prepares to percuss Calvin’s abdomen.
14.
A dull sound is heard when the nurse percusses over the suprapubic area. What action should the nurse take in response to this finding?
Ask the client to breathe deeply and percuss again.
Observe the area for bladder distention.
Determine if the client feels bloated or gaseous.
Assist the client to a sitting position immediately.

Answer 15

Observe the area for bladder distention.

A dull sound upon percussion may be heard over a distended bladder.

Question 16

While percussing the abdomen, the nurse hears tympany over most of the abdomen but notes a duller sound when percussing at the right costal margin.
15.
What follow-up action should the nurse take?
Note this location as the border of the liver.
Review the client’s past medical history.
Auscultate for adventitious breath sounds.
Document the presence of splenic dullness.

Answer 16

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 abdominal tympany should change to dullness over the liver border. This location is useful in determining liver span.

Question 17

16.
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?
 Deeply palpate each abdominal organ.
  Carefully palpate areas of tenderness.
  Lightly palpate the abdominal surface.
  Gently palpate the edges of the liver.

Answer 17

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.

Question 18

When beginning palpation of the client’s abdomen, the nurse uses a circular finger motion to depress the client’s skin about a half centimeter. While palpating, the nurse observes that the client’s superficial abdominal muscles are tensing bilaterally.
17.
What action should the nurse take?
Document the onset of rebound tenderness.
Observe the muscles while the client exhales.
Decrease the amount of pressure applied.
Stop any further palpation immediately.

Answer 18

Observe the muscles while the client exhales.
Bilateral tensing is often an indication of voluntary guarding by the client. To help distinguish between voluntary and involuntary guarding, the nurse should observe the muscles during exhalation because the client usually does not demonstrate voluntary guarding during exhalation.

Question 19

After palpating Calvin’s abdomen, the nurse observes that Calvin is very fatigued. He states that the nausea medication has made him very sleepy. The nurse concludes the assessment to allow Calvin to rest.
18.
Which information is most important to report to the nurse assuming responsibility for Calvin’s care?
The presence of striae on the client’s abdomen.
The client’s recent history of weight loss.
The time the client received an antiemetic.
The client’s intolerance of spicy foods.

Answer 19

The time the client received an antiemetic.
This information is essential to report to the nurse assuming responsibility for the client to ensure client safety after receiving a sedating medication.

Question 20

19.
During the report, the nurse also describes the client’s earlier emesis. The nurse should describe the emesis in terms of which characteristics?
Color and volume.
  Intensity and quality.
  Turgor and moisture.
  Dyspepsia and anorexia.

Answer 20

Color and volume.
It is important for the nurse to describe the appearance of the emesis, which includes the color and consistency and the volume, or amount, of emesis.

Question 21

Physical Assessment: A Change in Condition

Three hours later, Calvin’s wife calls the nurse, stating that he seems to be experiencing increasing abdominal pain.

The nurse asks Calvin where he is experiencing pain. He points to his right lower abdomen.
20.
When completing the pain assessment, how should the nurse assess for rebound tenderness?
Position the client on his right side.
Lightly palpate over the painful area.
Ask the client to describe the pain.
Push down on the left side of the abdomen.

Answer 21

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.

Question 22

21.
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 healthcare provider of the findings.
Assist the client to a semi-Fowler’s position.
Guide the client through relaxation exercises.
Place a warm moist pack on the client’s abdomen.

Answer 22

Notify the healthcare provider 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 healthcare provider immediately for further diagnostic evaluation.

Question 23

Related Assessment: Pain

After the nurse reports the findings to the healthcare provider, Calvin is scheduled for immediate surgery. Following surgery, Calvin returns to his room. During the nursing assessment on the first postoperative day, Calvin seems anxious and tells the nurse he “hurts a lot.”
22.
In response to the client’s statement that he “hurts a lot,” what action should the nurse take first?
Observe the appearance of the surgical incision.
Ask the client where he is experiencing the pain.
Determine when the client last received an analgesic.
Assess the client’s vital signs and oxygen saturation.

Answer 23

Ask the client where he is experiencing the pain.

The nurse should begin by gathering further data about the pain, including location, intensity, and quality.

Question 24

Medication Administration

23.
After completing the pain assessment, the nurse prepares to administer a prescribed opioid analgesic. Hydrocodone 10 mg by mouth every 6 hours is prescribed. Hydrocodone 5 mg per tablet is available. How many tablets should the nurse administer?

Answer 24

2

Question 25

Thirty minutes later, the nurse returns to the client’s room to assess Calvin’s response to the medication.
24.
Which finding provides the most useful data about the effectiveness of the medication?
The client’s vital signs are within normal limits.
The client is holding a pillow over his abdomen.
The client’s facial expression is calm and relaxed.
The client denies any lessening of his pain.

Answer 25

The client denies any lessening of his pain.
The client’s subjective report regarding his pain is the most important information for the nurse to assess when evaluating the effectiveness of analgesic administration.

Question 26

25.
To learn about the intensity of the client’s pain, what action should the nurse take?
Ask the client how well he normally tolerates daily aches and pains.
Determine what actions the client has already taken to reduce his pain.
Encourage the client to use a numeric pain scale to rate his pain.
Question the client about how the pain limits his ability to function.

Answer 26

Encourage the client to use a numeric pain scale to rate his pain. Correct
A numeric pain scale is an effective tool for measuring pain intensity.