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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View Related questions
Correct Answer is D
Explanation
Choice A reason:
Decreased abdominal distention is not typically a sign of appendicitis perforation. In fact, perforation often leads to increased abdominal distention due to the release of intestinal contents into the abdominal cavity, causing inflammation and swelling. Therefore, this choice is incorrect.
Choice B reason:
Anorexia, or loss of appetite, is a common symptom of appendicitis but not specifically indicative of perforation2. While anorexia can be present in cases of perforation, it is not a definitive sign. The sudden relief of pain is a more critical indicator of perforation, as it suggests the appendix has ruptured, temporarily relieving pressure.
Choice C reason:
Bradycardia, or a slow heart rate, is not a typical sign of appendicitis perforation. In fact, appendicitis and its complications, such as perforation, are more likely to cause tachycardia (an increased heart rate) due to pain and infection. Therefore, this choice is incorrect.
Choice D reason:
Sudden relief from pain is a classic sign of appendicitis perforation. When the appendix ruptures, the pressure inside the appendix is relieved, leading to a temporary decrease in pain. However, this is followed by a rapid onset of severe pain as the contents of the appendix spread throughout the abdominal cavity, causing peritonitis. This sudden change in pain is a critical indicator that the appendix has perforated and requires immediate medical attention.
Correct Answer is C
Explanation
Choice A Reason:
I will have my child rest: Resting is an important part of managing a bleeding episode in children with hemophilia. It helps to minimize movement and reduce the risk of further injury or bleeding.
Choice B Reason:
I will compress the site: Applying pressure to the bleeding site is a standard first aid measure for controlling bleeding. Compression helps to slow down or stop the bleeding by promoting clot formation.
Choice C Reason:
I will apply heat: Applying heat is not recommended for managing bleeding in hemophilia. Heat can increase blood flow to the area, potentially worsening the bleeding. Instead, cold compresses or ice packs should be used to constrict blood vessels and reduce bleeding.
Choice D Reason:
I will elevate the affected part: Elevating the affected limb can help reduce blood flow to the area and minimize bleeding. This is a common and effective first aid measure for managing bleeding episodes.