A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. Move the steps into the box in order of performance:
Inspection
Auscultation
Superficial palpation
Deep palpation
Correct Answer : A,B,C,D
The correct answer is a) Inspection, b) Auscultation, c) Superficial palpation, d) Deep palpation.
Choice A reason:
Inspection is the first step in an abdominal assessment. This involves visually examining the abdomen for any abnormalities such as distension, scars, lesions, or asymmetry. The nurse should note the shape, contour, and any visible movements or pulsations. This step is crucial as it provides the initial information about the patient’s condition and helps guide the subsequent steps of the assessment.
Choice B reason:
Auscultation follows inspection in the sequence of an abdominal assessment. The nurse uses a stethoscope to listen for bowel sounds in all four quadrants of the abdomen. This step is performed before palpation to avoid altering the natural bowel sounds. The presence, frequency, and character of bowel sounds can provide valuable information about the gastrointestinal function and help identify any abnormalities such as bowel obstruction or ileus.
Choice C reason:
Superficial palpation is the third step in the abdominal assessment sequence. The nurse gently palpates the abdomen to assess for tenderness, muscle tone, and any superficial masses. This step helps identify areas of discomfort or pain and provides information about the condition of the abdominal wall and underlying structures. It is important to perform this step gently to avoid causing discomfort or pain to the patient.
Choice D reason:
Deep palpation is the final step in the abdominal assessment sequence. The nurse applies more pressure to palpate deeper structures within the abdomen. This step helps assess for any deep-seated masses, organ enlargement, or areas of tenderness that were not detected during superficial palpation. Deep palpation should be performed carefully to avoid causing pain or discomfort to the patient.
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Correct Answer is C
Explanation
Choice A Reason:
“Watch how well I blow these bubbles” is not a concerning statement. It indicates that the child is engaging in normal activities and is not experiencing any distress related to the cast or the injury.
Choice B Reason:
“My skin is so itchy under there” is a common complaint among children with casts. Itchiness can be managed with appropriate care, such as using a hair dryer on a cool setting to blow air under the cast. However, it is not an immediate cause for concern.
Choice C Reason:
“My toes feel like they are sleeping and won’t wiggle when I tell them to” is a concerning statement. This could indicate nerve compression or impaired circulation, which are serious complications that require immediate medical attention. Prompt evaluation is necessary to prevent permanent damage.
Choice D Reason:
“I was able to ride on the scooter with the PT person’s help” is not a concerning statement. It suggests that the child is participating in physical therapy and is able to move with assistance, which is a positive sign of recovery.
Correct Answer is B
Explanation
Choice A Reason:
Compartment syndrome is a condition where increased pressure within a muscle compartment leads to decreased blood flow, which can cause muscle and nerve damage. It is typically associated with severe trauma, fractures, or crush injuries. The symptoms include severe pain, swelling, and decreased sensation or movement in the affected limb. In this case, the child’s symptoms of redness, swelling, and tenderness following a spider bite, along with an elevated WBC, are more indicative of an infection rather than compartment syndrome.
Choice B Reason:
Osteomyelitis is an infection of the bone, which can occur following an injury or infection elsewhere in the body. The symptoms include redness, swelling, tenderness, and pain in the affected area, along with fever and elevated WBC. Given the child’s history of a spider bite and the presence of redness, swelling, tenderness, and elevated WBC, osteomyelitis is the most likely diagnosis. The unremarkable X-ray does not rule out osteomyelitis, as early stages of the infection may not show changes on X-ray.
Choice C Reason:
Osteogenesis imperfecta, also known as brittle bone disease, is a genetic disorder characterized by fragile bones that break easily. It is not associated with infections or elevated WBC. The symptoms of osteogenesis imperfecta include frequent fractures, blue sclerae, and hearing loss. The child’s symptoms of redness, swelling, and tenderness following a spider bite, along with an elevated WBC, are not consistent with osteogenesis imperfecta.
Choice D Reason:
Juvenile idiopathic arthritis (JIA) is a type of arthritis that occurs in children. It is characterized by persistent joint inflammation, pain, and swelling. While JIA can cause joint tenderness and swelling, it is not typically associated with a recent injury or infection, such as a spider bite. Additionally, JIA does not usually cause elevated WBC. The child’s symptoms are more indicative of an infection, making osteomyelitis the more likely diagnosis.