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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A Reason:
Foster self-care activities: Encouraging self-care activities is important for children with hemiplegic cerebral palsy as it promotes independence and self-esteem. However, it is not the highest priority compared to ensuring the child’s safety and accessibility in their home environment.
Choice B Reason:
Improve the child’s communication skills: Enhancing communication skills is crucial for the child’s social and emotional development. Effective communication can significantly improve the child’s quality of life. However, while important, it is not the most immediate priority compared to modifying the home environment for safety.
Choice C Reason:
Modify the home environment for safety and accessibility: Ensuring the home environment is safe and accessible is the top priority. Children with hemiplegic cerebral palsy may have mobility challenges, and a safe environment can prevent injuries and promote independence. This modification directly impacts the child’s daily life and overall well-being.
Choice D Reason:
Provide respite services for the parents: Offering respite services is beneficial for the parents’ mental and emotional health, allowing them to take breaks and recharge. While this is important, it is not the primary concern compared to the child’s immediate safety and accessibility needs.
Correct Answer is D
Explanation
Choice A reason:
Infarction of the renal vessels is not a common consequence of vesicoureteral reflux (VUR). Infarction refers to tissue death due to a lack of blood supply, which is not typically associated with VUR1. VUR primarily affects the urinary tract, leading to the backward flow of urine from the bladder into the ureters and kidneys. This condition can cause other complications, but infarction of the renal vessels is not one of them.
Choice B reason:
Renal calculi, or kidney stones, are not directly caused by vesicoureteral reflux. While VUR can lead to urinary tract infections (UTIs), which may increase the risk of developing kidney stones, it is not the primary outcome. Kidney stones are typically formed due to an imbalance of minerals and salts in the urine, leading to crystallization. VUR itself does not directly cause the formation of renal calculi.
Choice C reason:
Urinary obstruction is not a typical result of vesicoureteral reflux. VUR involves the backward flow of urine, but it does not usually cause a physical blockage in the urinary tract. Urinary obstruction can occur due to other conditions, such as congenital abnormalities, tumors, or kidney stones, but it is not a direct consequence of VUR.
Choice D reason:
Recurrent kidney infections are a common complication of vesicoureteral reflux. The backward flow of urine can carry bacteria from the bladder into the kidneys, leading to repeated episodes of pyelonephritis (kidney infection). These recurrent infections can cause kidney damage over time if not properly managed. Therefore, it is crucial to monitor and treat VUR to prevent recurrent kidney infections and preserve kidney function.
