Health Assessment Case 3: Sara Lin vSim
1. Patient states, "I felt a very sharp pain as you let up on the pressure to my
stomach.": During an abdominal assessment the nurse is assessing for rebound
tenderness. Which response by the patient indicates a positive Blumberg's sign?
2. Encourage the patient to take deep, slow breaths , Begin palpation by placing your
hand over the patient's hand , Apply light pressure to the patient'ssternum when
palpating: Which nursing interventions will minimize a patient's voluntary guarding
during the palpation required of an abdominal assessment? (Select all that apply.)
Encourage the patient to take deep, slow breaths
Begin palpation by placing your hand over the patient's handApply
light pressure to the patient's sternum when palpatingEncourage
the patient to tighten the abdominal muscles Place a pillow under
the patient's lumbar region
3. Asking the patient to rate the degree of abdominal pain on a scale of 0 to 10: Which
nursing action best supports the nurse's attempt to collect the appropriatesubjective data
during a pain assessment related to abdominal pain?
4. What would you rate your pain now that your pain medication has had time to
take effect?: Regarding the reassessment of a patient's pain, which state-ment/question by
the nurse demonstrates an understanding of appropriate nursingmanagement?
5. Asking oneself, "How do I react differently from others when I am in pain?"-
: Which activity is at the foundation of a nurse's personal ability to provide culturally
competent, unbiased nursing care associated with pain management?
6. What do you usually do to manage your chronic pain?: Which statement bythe
nurse during a pain assessment demonstrates the best understanding of the need to avoid
stereotypes when working with a member of an Asian cultural groupwho has a history of
rheumatoid arthritis?
7. Auscultate to assess for bowel sounds: The nurse conducting an abdominal
assessment has completed the inspection of the abdominal area. Which action by the nurse
will then follow?
8. Assess the patient for a positive Blumberg's sign: The nurse is conducting an
abdominal assessment on a patient diagnosed with possible acute appendix in-flammation.
Which nursing action would be appropriate when assessing for referredpain?
9. My documentation of a patient's assessment data will assist in the develop-ment of
an effective, safe plan of care.: Which statement best demonstrates thenurse's
understanding of the primary goal of effective, appropriate documentation of a patient's
assessment data?
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1. Patient states, "I felt a very sharp pain as you let up on the pressure to my
stomach.": During an abdominal assessment the nurse is assessing for rebound
tenderness. Which response by the patient indicates a positive Blumberg's sign?
2. Encourage the patient to take deep, slow breaths , Begin palpation by placing your
hand over the patient's hand , Apply light pressure to the patient'ssternum when
palpating: Which nursing interventions will minimize a patient's voluntary guarding
during the palpation required of an abdominal assessment? (Select all that apply.)
Encourage the patient to take deep, slow breaths
Begin palpation by placing your hand over the patient's handApply
light pressure to the patient's sternum when palpatingEncourage
the patient to tighten the abdominal muscles Place a pillow under
the patient's lumbar region
3. Asking the patient to rate the degree of abdominal pain on a scale of 0 to 10: Which
nursing action best supports the nurse's attempt to collect the appropriatesubjective data
during a pain assessment related to abdominal pain?
4. What would you rate your pain now that your pain medication has had time to
take effect?: Regarding the reassessment of a patient's pain, which state-ment/question by
the nurse demonstrates an understanding of appropriate nursingmanagement?
5. Asking oneself, "How do I react differently from others when I am in pain?"-
: Which activity is at the foundation of a nurse's personal ability to provide culturally
competent, unbiased nursing care associated with pain management?
6. What do you usually do to manage your chronic pain?: Which statement bythe
nurse during a pain assessment demonstrates the best understanding of the need to avoid
stereotypes when working with a member of an Asian cultural groupwho has a history of
rheumatoid arthritis?
7. Auscultate to assess for bowel sounds: The nurse conducting an abdominal
assessment has completed the inspection of the abdominal area. Which action by the nurse
will then follow?
8. Assess the patient for a positive Blumberg's sign: The nurse is conducting an
abdominal assessment on a patient diagnosed with possible acute appendix in-flammation.
Which nursing action would be appropriate when assessing for referredpain?
9. My documentation of a patient's assessment data will assist in the develop-ment of
an effective, safe plan of care.: Which statement best demonstrates thenurse's
understanding of the primary goal of effective, appropriate documentation of a patient's
assessment data?
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