Essay on Fundamental Case Study

3538 Words Jan 25th, 2014 15 Pages
1. 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.Which assessment should the nurse complete first?
A. Auscultate the bowel sounds.
Another assessment should be completed before assessing the client’s bowel sounds.
B. Palpate for abdominal distention.
Another assessment should be completed before assessing for distention.
C. Correct Observe the color of the emesis.
Since the client is vomiting, the nurse should first observe the color
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G. Observe for any visible peristalsis.
The presence of visible peristalsis does not provide information related to the symmetry of the abdomen.
H. Correct Inspect for masses or bulges.
The presence of masses or bulges will alter the symmetry of the abdomen, resulting in an asymmetric shape.
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?
A. Depressed umbilicus.
This normal finding is not related to the presence or absence of an aortic pulsation.
B. Correct 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.
C. Dark brown skin pigmentation.
This finding, normal in an African American client, is not related to the presence or absence of an aortic pulsation.
D. Abdominal movement with respirations.
This normal finding is not related to the presence or absence of an aortic pulsation.
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.)
E. Date of last bowel movement.
This information

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