NURSING ASSESSMENT & NOTES06/06 2100 Neuro/Cognitive: Alert and oriented to person, place, time, and situation. Gastrointestinal: BS present x 4 quadrants. Abdomen diffusely tender, distended. Last bowel movement x 1 day ago. +nausea/vomiting. Bilious colored emesis. Rates 9/10 constant epigastric pain.06/06 2105 Situation: Ms. Sigmund is in room 5. She just checked in, and I performed her assessment. She is vomiting up bilious emesis about every 5 minutes. She is reporting 9/10 abdominal pain located in the epigastric region. Background: Ms. Sigmund is a 39-year-old female with a history of alcohol abuse and gallstones. She is a current everyday smoker. Assessment: Her abdomen is distended and tender. She has a fever of 101.1°F. Other vital signs are all normal. Recommendation: I am requesting a prescription for pain and nausea medicine. I would like you to see the client as soon as you can step away. Question 2 Not complete Marked out of 33.34 Question text Before answering this question, review the client’s health information in the EHR. Indicate the diagnostic tests that are anticipated for this client. Select one option in each row. Anticipated Not Anticipated CBC Chest x-ray Abdominal CT Kidney ultrasound Liver enzymes Serum bilirubin Head CT Pancreatic enzymes
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