CASE STUDY ABDOMINAL
ASSESSMENT
EXAM
Management of CareMrs. McElroy is admitted to her room accompanied by her husband. Before the
nurse can begin the admission assessment, Mrs. McElroy states that she needs to throw up. The nurse
helps Mrs. McElroy sit up and provides an emesis basin.Mrs. McElroy vomits into the emesis basin and
then remains sitting on the side of the bed, stating that she may need to throw up again. Which
assessment should the nurse complete first? - CORRECT ANSWER-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.
Mrs. McElroy continues to feel nauseated and Mr. McElroy remains with his wife while the nurse leaves
the room to prepare a PRN dose of a prescribed antiemetic. Shortly after the nurse administers the
antiemetic, Mrs. McElroy 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? - CORRECT ANSWER-Observe for excessive dryness 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, Mrs. McElroy stops vomiting, appears relaxed, and
denies further nausea. She states that she is comfortable enough for the nurse to begin the admission
assessment and asks that the nurse call her Claudine.
The nurse begins the client interview, focusing on the gastrointestinal system. For the nurse to learn
about Claudine's bowel patterns, which questions are most important to ask Claudine? - CORRECT
ANSWER-Do you take any prescription or over-the-counter medications?
Medications can cause adverse GI effects.
Have you noticed any change in your stool pattern?
Changes in bowel habits can be due to various etiologies, such as diet, stress, activity and medications.
Do you have 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.
Do you have frequent vomiting episodes?
, This information is an important part of the client's history.
The nurse asks Claudine if there are any foods she cannot eat, and Claudine reports that she doesn't
tolerate spicy foods.
What questions should the nurse ask next? - CORRECT ANSWER-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?
Claudine's response is the most useful regarding the nature of her inability to eat spicy foods and any
underlying problems.
Do you remember when you developed this intolerance to spicy foods?
This information is useful in assessing the client's inability to eat spicy foods.
Health Promotion and Maintenance
After completing the client interview, the nurse is ready to begin the physical assessment of the
abdomen.
The nurse prepares Claudine for the physical assessment of the abdomen. Before assisting her to a
supine position, what action should the nurse take? - CORRECT ANSWER-Encourage the client to empty
her bladder.
Emptying the bladder will help promote relaxation of the abdominal wall.
Discuss the sequence of steps performed during the abdominal assessment.
Telling the client what to expect during a procedure helps promote relaxation.
After completing the preparations, the nurse assists Claudine to a supine position on the bed.
To assess the symmetry of the abdomen, what action should the nurse take? - CORRECT ANSWER-
Observe the abdomen from two different angles.
To evaluate symmetry, the nurse should stand behind the client's head and squat at the side to view the
abdomen at eye level.
The assessment reveals that the client's abdomen is symmetrical with no masses, bulges, or pulsation
of the abdominal aorta observed.
The nurse notes dark brown pigmentation on the abdominal area. Which action is most important for the
nurse to perform next? - CORRECT ANSWER-Document the finding as normal.
This is a normal finding in the African American client. The nurse should document the finding.
While inspecting Claudine's abdomen, the nurse observes silvery white striae on the lower abdomen. In
response to this finding, what information should the nurse obtain? - CORRECT ANSWER-Past medical
history of ascites.
ASSESSMENT
EXAM
Management of CareMrs. McElroy is admitted to her room accompanied by her husband. Before the
nurse can begin the admission assessment, Mrs. McElroy states that she needs to throw up. The nurse
helps Mrs. McElroy sit up and provides an emesis basin.Mrs. McElroy vomits into the emesis basin and
then remains sitting on the side of the bed, stating that she may need to throw up again. Which
assessment should the nurse complete first? - CORRECT ANSWER-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.
Mrs. McElroy continues to feel nauseated and Mr. McElroy remains with his wife while the nurse leaves
the room to prepare a PRN dose of a prescribed antiemetic. Shortly after the nurse administers the
antiemetic, Mrs. McElroy 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? - CORRECT ANSWER-Observe for excessive dryness 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, Mrs. McElroy stops vomiting, appears relaxed, and
denies further nausea. She states that she is comfortable enough for the nurse to begin the admission
assessment and asks that the nurse call her Claudine.
The nurse begins the client interview, focusing on the gastrointestinal system. For the nurse to learn
about Claudine's bowel patterns, which questions are most important to ask Claudine? - CORRECT
ANSWER-Do you take any prescription or over-the-counter medications?
Medications can cause adverse GI effects.
Have you noticed any change in your stool pattern?
Changes in bowel habits can be due to various etiologies, such as diet, stress, activity and medications.
Do you have 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.
Do you have frequent vomiting episodes?
, This information is an important part of the client's history.
The nurse asks Claudine if there are any foods she cannot eat, and Claudine reports that she doesn't
tolerate spicy foods.
What questions should the nurse ask next? - CORRECT ANSWER-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?
Claudine's response is the most useful regarding the nature of her inability to eat spicy foods and any
underlying problems.
Do you remember when you developed this intolerance to spicy foods?
This information is useful in assessing the client's inability to eat spicy foods.
Health Promotion and Maintenance
After completing the client interview, the nurse is ready to begin the physical assessment of the
abdomen.
The nurse prepares Claudine for the physical assessment of the abdomen. Before assisting her to a
supine position, what action should the nurse take? - CORRECT ANSWER-Encourage the client to empty
her bladder.
Emptying the bladder will help promote relaxation of the abdominal wall.
Discuss the sequence of steps performed during the abdominal assessment.
Telling the client what to expect during a procedure helps promote relaxation.
After completing the preparations, the nurse assists Claudine to a supine position on the bed.
To assess the symmetry of the abdomen, what action should the nurse take? - CORRECT ANSWER-
Observe the abdomen from two different angles.
To evaluate symmetry, the nurse should stand behind the client's head and squat at the side to view the
abdomen at eye level.
The assessment reveals that the client's abdomen is symmetrical with no masses, bulges, or pulsation
of the abdominal aorta observed.
The nurse notes dark brown pigmentation on the abdominal area. Which action is most important for the
nurse to perform next? - CORRECT ANSWER-Document the finding as normal.
This is a normal finding in the African American client. The nurse should document the finding.
While inspecting Claudine's abdomen, the nurse observes silvery white striae on the lower abdomen. In
response to this finding, what information should the nurse obtain? - CORRECT ANSWER-Past medical
history of ascites.
