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 D
Explanation
Choice A reason:
A 7-year-old child with diabetes insipidus and a urine specific gravity of 1.016 is not in immediate danger. Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of severely diluted urine. A urine specific gravity of 1.016 is within the normal range (1.005 to 1.030). Therefore, this child does not require immediate assessment.
Choice B reason:
A 4-year-old child with asthma and a PCO2 of 37 mm Hg is also not in immediate danger. Asthma is a chronic condition that can cause difficulty breathing, but a PCO2 level of 37 mm Hg is within the normal range (35-45 mm Hg). This indicates that the child’s respiratory status is currently stable, and immediate assessment is not required.
Choice C reason:
A 1-year-old toddler with roseola and a temperature of 39°C (102.2°F) is experiencing a common viral infection that typically causes a high fever followed by a rash. While the fever is high, it is not uncommon for roseola and can be managed with antipyretics and supportive care. This child does not require immediate assessment.
Choice D reason:
A 10-year-old child with sickle cell anemia reporting 8 out of 10 chest pain is in immediate danger and requires urgent assessment. Chest pain in a child with sickle cell anemia can indicate acute chest syndrome, a severe and potentially life-threatening complication. Acute chest syndrome is characterized by chest pain, fever, and respiratory distress, and it requires prompt medical intervention. Therefore, this child should be assessed first.
Correct Answer is A
Explanation
Choice A Reason:
Weight loss despite increased eating is a classic symptom of type 1 diabetes mellitus in children. This occurs because the body is unable to use glucose for energy due to a lack of insulin. As a result, the body starts breaking down fat and muscle for energy, leading to weight loss even though the child may have an increased appetite.
Choice B Reason:
Pale, moist skin is not typically associated with type 1 diabetes mellitus. This symptom is more commonly related to conditions such as anemia or infections. In type 1 diabetes, the skin may actually appear dry due to dehydration caused by high blood sugar levels.
Choice C Reason:
Weight gain and fluid overload are not characteristic of type 1 diabetes mellitus. In fact, children with type 1 diabetes often experience weight loss. Fluid overload is more commonly seen in conditions such as heart failure or kidney disease.
Choice D Reason:
Poor sleep with frequent awakening is not a specific symptom of type 1 diabetes mellitus. While children with diabetes may experience nocturia (frequent urination at night) due to high blood sugar levels, this is not the primary clinical manifestation. The main symptoms are related to hyperglycemia and the body’s inability to use glucose for energy.