NU271 Case Study: Constipation (week 11) Test with Answers
Meet the Client - ANSWER -A client on the Begin auscultation in the right lower quadrant.
medical surgical unit had an abdominal (The nurse should auscultate in the right lower
hysterectomy three days ago and is now quadrant, and then proceed to the other
reporting abdominal bloating, pain, and nausea. quadrants.)
She is reluctant to eat or drink anything stating,
"The smell of food makes me nauseated." She
informs the nurse that she feels constipated and The nurse auscultates for the client's bowel
has not passed a bowel movement since prior to sounds and hears faint gurgling after 3 minutes.
surgery. Which assessment finding should the nurse
document? - ANSWER -Hypoactive bowel
sounds.
Health Promotion and Maintenance - -
ANSWER -The nurse observes the client's Normally, bowel sounds are heard 5 to 35 times
abdomen is firm and distended. The nurse per minute. When bowel sounds are heard only
performs an abdominal assessment. after listening for 3 minutes, they are recorded as
hypoactive.
In which sequence should the nurse perform the
abdominal assessment? - ANSWER - Psychosocial Integrity - ANSWER -While
Inspection, auscultation, percussion, palpation. the nurse is completing the assessment, the
- client begins to cry and moan, "I just knew
Percussion and palpation can alter abdominal something would go wrong."
findings, so inspection and auscultation are
indicated prior to percussion and palpation.
How should the nurse respond? -
ANSWER -"Tell me what is making you feel
Which assessment is most important for the so upset."
nurse to perform? - ANSWER -Auscultate -
bowel sounds. This open-ended statement encourages the client
- to express further concerns and fears.
The subjective data reported by the client
(bloated and nauseated) and objective data
gathered by the nurse (abdomen firm and Which response by the nurse will encourage
distended) suggest that she may have continued verbalization by the client? -
decreased peristalsis. This can be assessed by ANSWER -"It sounds as if you have had
auscultation of the bowel sounds. another experience that did not go well."
-
The nurse's response validates the client's
Which is the most important action for the nurse feelings, which will encourage her to verbalize
to perform when assessing bowel sounds? further.
(Select all that apply.) - ANSWER -Listen
for up to 5 minutes when auscultating for bowel
sounds. (The nurse must listen for up to 5 The nurse informs the client that she has
minutes before determining what type of bowel developed constipation. The client tells the nurse,
sounds are present.) "I hate hospitals because nobody ever tells you
- what's happening, and you end up with all these
1/4
Meet the Client - ANSWER -A client on the Begin auscultation in the right lower quadrant.
medical surgical unit had an abdominal (The nurse should auscultate in the right lower
hysterectomy three days ago and is now quadrant, and then proceed to the other
reporting abdominal bloating, pain, and nausea. quadrants.)
She is reluctant to eat or drink anything stating,
"The smell of food makes me nauseated." She
informs the nurse that she feels constipated and The nurse auscultates for the client's bowel
has not passed a bowel movement since prior to sounds and hears faint gurgling after 3 minutes.
surgery. Which assessment finding should the nurse
document? - ANSWER -Hypoactive bowel
sounds.
Health Promotion and Maintenance - -
ANSWER -The nurse observes the client's Normally, bowel sounds are heard 5 to 35 times
abdomen is firm and distended. The nurse per minute. When bowel sounds are heard only
performs an abdominal assessment. after listening for 3 minutes, they are recorded as
hypoactive.
In which sequence should the nurse perform the
abdominal assessment? - ANSWER - Psychosocial Integrity - ANSWER -While
Inspection, auscultation, percussion, palpation. the nurse is completing the assessment, the
- client begins to cry and moan, "I just knew
Percussion and palpation can alter abdominal something would go wrong."
findings, so inspection and auscultation are
indicated prior to percussion and palpation.
How should the nurse respond? -
ANSWER -"Tell me what is making you feel
Which assessment is most important for the so upset."
nurse to perform? - ANSWER -Auscultate -
bowel sounds. This open-ended statement encourages the client
- to express further concerns and fears.
The subjective data reported by the client
(bloated and nauseated) and objective data
gathered by the nurse (abdomen firm and Which response by the nurse will encourage
distended) suggest that she may have continued verbalization by the client? -
decreased peristalsis. This can be assessed by ANSWER -"It sounds as if you have had
auscultation of the bowel sounds. another experience that did not go well."
-
The nurse's response validates the client's
Which is the most important action for the nurse feelings, which will encourage her to verbalize
to perform when assessing bowel sounds? further.
(Select all that apply.) - ANSWER -Listen
for up to 5 minutes when auscultating for bowel
sounds. (The nurse must listen for up to 5 The nurse informs the client that she has
minutes before determining what type of bowel developed constipation. The client tells the nurse,
sounds are present.) "I hate hospitals because nobody ever tells you
- what's happening, and you end up with all these
1/4
