NURS624 Case Study: Constipation Exam
questions and answers
The nurse observes the client's abdomen is firm and distended. The nurse performs an abdominal
assessment.
In which sequence should the nurse perform the abdominal assessment?
A. Auscultation, inspection, percussion, palpation.
B. Inspection, palpation, auscultation, percussion.
C. Inspection, auscultation, percussion, palpation.
D. Auscultation, percussion, inspection, palpation.
C
Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior
to percussion and palpation.
Which action is most important for the nurse to perform?
A. Auscultate bowel sounds.
B. Measure abdominal girth.
C. Observe incisional staples.
D. Measure blood pressure.
A
The subjective data reported by the client (bloated and nauseated) and objective data gathered by the
nurse (abdomen firm and distended) suggest that she may have decreased peristalsis. This can be
assessed by auscultation of the bowel sounds.
Which is the most important action for the nurse to perform when assessing bowel sounds? (Select all
that apply.)
A. Ask the client if she has lost or gained any weight.
B. Listen for up to 5 minutes when auscultating for bowel sounds.
C. Perform a rectal exam.
D. Inspect the client’s abdomen while she is in a semi-Fowler's position.
E. Begin auscultation in the right lower quadrant.
B, E
, The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present.
The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants.
See an expert-written answer!
The nurse auscultates for the client's bowel sounds and hears faint gurgling after 3 minutes. Which
assessment finding should the nurse document?
A. Hypoactive bowel sounds.
B. Normal bowel sounds.
C. Paralytic ileus.
D. Reduced peristalsis.
A
Normally, bowel sounds are heard 5 to 35 times per minute. When bowel sounds are heard only after
listening for 3 minutes, they are recorded as hypoactive.
While the nurse is interviewing the client, she begins to cry and moan, and states she just knew
something would go wrong.
How should the nurse respond?
A. This is a minor problem. We'll have you better very soon.
B. You have to expect that problems will occur after surgery.
C. Tell me what is making you feel so upset.
D. Why are you letting this upset you?
C
This open-ended statement encourages the client to express further concerns and fears.
Which response by the nurse will encourage continued verbalization by the client?
A. All of the nurses are very busy here, and they are doing the best job they can.
B. You should write down your questions so you can get some answers.
C. I will be happy to tell you everything that's happening, so nothing else will go wrong.
D. It sounds as if you have had another experience that did not go well.
D
The nurse's response validates the client's feelings, which will encourage her to verbalize further.
The nurse informs the client that she has developed constipation. The client tells the nurse that she
hates hospitals because nobody ever tells you what's happening, and you end up with all these things
questions and answers
The nurse observes the client's abdomen is firm and distended. The nurse performs an abdominal
assessment.
In which sequence should the nurse perform the abdominal assessment?
A. Auscultation, inspection, percussion, palpation.
B. Inspection, palpation, auscultation, percussion.
C. Inspection, auscultation, percussion, palpation.
D. Auscultation, percussion, inspection, palpation.
C
Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior
to percussion and palpation.
Which action is most important for the nurse to perform?
A. Auscultate bowel sounds.
B. Measure abdominal girth.
C. Observe incisional staples.
D. Measure blood pressure.
A
The subjective data reported by the client (bloated and nauseated) and objective data gathered by the
nurse (abdomen firm and distended) suggest that she may have decreased peristalsis. This can be
assessed by auscultation of the bowel sounds.
Which is the most important action for the nurse to perform when assessing bowel sounds? (Select all
that apply.)
A. Ask the client if she has lost or gained any weight.
B. Listen for up to 5 minutes when auscultating for bowel sounds.
C. Perform a rectal exam.
D. Inspect the client’s abdomen while she is in a semi-Fowler's position.
E. Begin auscultation in the right lower quadrant.
B, E
, The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present.
The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants.
See an expert-written answer!
The nurse auscultates for the client's bowel sounds and hears faint gurgling after 3 minutes. Which
assessment finding should the nurse document?
A. Hypoactive bowel sounds.
B. Normal bowel sounds.
C. Paralytic ileus.
D. Reduced peristalsis.
A
Normally, bowel sounds are heard 5 to 35 times per minute. When bowel sounds are heard only after
listening for 3 minutes, they are recorded as hypoactive.
While the nurse is interviewing the client, she begins to cry and moan, and states she just knew
something would go wrong.
How should the nurse respond?
A. This is a minor problem. We'll have you better very soon.
B. You have to expect that problems will occur after surgery.
C. Tell me what is making you feel so upset.
D. Why are you letting this upset you?
C
This open-ended statement encourages the client to express further concerns and fears.
Which response by the nurse will encourage continued verbalization by the client?
A. All of the nurses are very busy here, and they are doing the best job they can.
B. You should write down your questions so you can get some answers.
C. I will be happy to tell you everything that's happening, so nothing else will go wrong.
D. It sounds as if you have had another experience that did not go well.
D
The nurse's response validates the client's feelings, which will encourage her to verbalize further.
The nurse informs the client that she has developed constipation. The client tells the nurse that she
hates hospitals because nobody ever tells you what's happening, and you end up with all these things
