The nurse is performing an abdominal assessment on a client who ...

[Sportsfan2111]

The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. As the nurse inspected the client's abdomen and notes ascites. Based on this data, which interventions will the nurse perform next?
 
  Select all that apply.
  1. Obtain stool specimen for occult blood.
  2. Measure the client's abdominal girth.
  3. Obtain stool specimen for culture and sensitivity.
  4. Bilateral leg measurements.
  5. Percuss the abdomen at midline.

Question 2

The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the stethoscope. The nurse hears a soft, continuous humming sound. Based on this data, the nurse suspects dysfunction with which organ?
 
  1. Stomach.
  2. Spleen.
  3. Pancreas.
  4. Liver.

[leannegxo]

Answer to Question 1

Correct Answer: 2, 5
The nurse should measure the client's abdominal girth to obtain baseline information for further comparisons. The nurse should percuss the abdomen at midline for tympany because this is a sign of ascites. The nurse would not necessarily suspect that the client had occult blood in the stool. The nurse does not need to send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed that the client had an infection within the gastrointestinal tract. The nurse does not necessarily need to measure the circumferences of the client's legs for edema.

Answer to Question 2

Correct Answer: 4
The nurse is hearing an abnormal abdominal sound called a venous hum, which is indicative of portal hypertension. Portal hypertension is the result of liver congestion. Dysfunction in the client's stomach, spleen, or pancreas most likely did not result in this type of sound.