Constipation Case Study questions and answers
1. The nurse observes that Joan's abdomen is firm and distended. The nurse performs an abdominal assessment. In what sequence should the nurse perform the abdominal assessment?
A. Auscultation, Inspection, Percussion, Palpation
B. Inspection, Palpati...
Constipation Case Study questions and
answers
1. The nurse observes that Joan's abdomen is firm and distended. The nurse performs an abdominal
assessment. In what sequence should the nurse perform the abdominal assessment?
A. Auscultation, Inspection, Percussion, Palpation
B. Inspection, Palpation, Auscultation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior
to percussion and palpation.
2. Which assessment is most important for the nurse to perform?
A. Auscultate bowel sounds.
B. Measure abdominal girth.
C. Observe incisional staples.
D. Measure bloop pressure -Correct Answer-A. Auscultate bowl sounds.
Based on subjective data by Joan (bloated and nauseated) and objective data by the nurse (abdomen
firm and distended), the nurse's first concern is that Joan may have decreased peristalsis.
3. In assessing bowl sounds, it is most important for the nurse to perform which action?
A. Ask the client when she had her last bowel movement.
B. Listen for up to 5 minutes when auscultating the bowl sounds.
C. Perform a rectal exam.
D. Place client in knee-chest position to expel excess gas prior to auscultation. -Correct Answer-B. Listen
for up to 5 minutes when auscultating for bowel sounds.
The nurse must listen for up to 5 minutes before determining what type of bowl sounds are present.
, 4. The nurse auscultates for Joan's bowel sounds and hears faint gurgling sounds after 3 minutes. How
will the nurse record this finding?
A. Hypoactive bowel sounds.
B. Normal bowel sounds.
C. Paralytic ileus.
D. Reduced peristalsis. -Correct Answer-A. Hypoactive bowel sounds.
Normally, bowel sounds are heard 5-35 times per minute. When bowel sounds are heard only after
listening for 3 minutes, they are recorded as hypoactive.
5. While the nurse is completing the assessment, Joan begins to cry and laments, "I 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?" -Correct Answer-C. "Tell me what is making you fell so upset."
This open-ended statement encourages the client to express further concerns and fears.
6. Which response by the nurse will encourage continued verbalization by the client?
A. "All 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." -Correct Answer-D. "It sounds
as if you have had another experience that did not go well."
The nurse's response validates Joan's feelings, which will encourage Joan to verbalize further.
7. How should the nurse respond?
A. Refer to the client to the surgeon to answer any questions about the surgical outcome.
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