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 ["B","C","D","E","F","H"]
Explanation
Choice A Reason: Unable to roll over back to front:
At 3 months, infants typically start to develop the ability to roll over from their stomach to their back. Rolling over from back to front usually occurs later, around 4 to 6 months. However, the inability to roll over at all by 3 months could indicate developmental delays or muscle weakness, which requires follow-up.
Choice B Reason:Head lag:
By 3 months, infants should have enough neck muscle strength to hold their head up when pulled to a sitting position. Persistent head lag at this age can be a sign of developmental delay or neuromuscular disorders, necessitating further evaluation.
Choice C Reason:Feeding difficulties:
Infants should be able to suck and swallow effectively by 3 months. Feeding difficulties can lead to inadequate nutrition and growth, and may indicate underlying issues such as gastrointestinal problems or neurological disorders. This requires prompt attention and intervention.
Choice D Reason:Floppy posture:
A 3-month-old should start to show more control over their body movements and have a more stable posture. Floppy posture, also known as hypotonia, can be a sign of various conditions, including genetic disorders, muscle diseases, or central nervous system issues. It is important to investigate the cause of hypotonia.
Choice E Reason:Arms are stiff:
Stiffness in the arms, or hypertonia, can indicate neurological problems such as cerebral palsy or other motor disorders. It is crucial to assess the underlying cause of increased muscle tone and provide appropriate interventions.
Choice F Reason:Does not smile:
Social smiling typically begins around 6 to 8 weeks of age. If a 3-month-old does not smile, it could be a sign of developmental delay, visual impairment, or other social and emotional issues. This warrants further assessment to determine the cause.
Choice G Reason:Unable to sit without support:
While sitting without support is not expected until around 6 months, the inability to show any signs of trying to sit or maintain a sitting position with support at 3 months could indicate developmental delays. This should be monitored and addressed if necessary.
Choice H Reason:Irritable and cries often:
Excessive irritability and frequent crying can be signs of discomfort, pain, or underlying medical conditions such as infections, gastrointestinal issues, or neurological problems. It is important to identify and address the cause of the infant’s distress.
Choice I Reason:Unable to pass an object between hands:
By 3 months, infants should start to develop hand-eye coordination and the ability to grasp objects. The inability to pass an object between hands may indicate developmental delays or motor skill issues, which require further evaluation.
Correct Answer is C
Explanation
Choice A reason:
Opioid analgesics are not given as a last resort solely because of the threat of addiction. While the risk of addiction is a concern, opioids are often necessary for managing severe pain, especially in conditions like sickle cell anemia. The American Society of Hematology guidelines emphasize the importance of effective pain management in sickle cell disease, which often includes the use of opioids. The goal is to manage pain effectively while monitoring for signs of misuse or addiction.
Choice B reason:
Opioid analgesics are often ordered and are usually needed for managing severe pain in patients with sickle cell anemia. Pain episodes in sickle cell disease can be extremely severe and debilitating, requiring potent analgesics like morphine for relief. The management of acute vaso-occlusive pain in sickle cell disease often necessitates the use of opioids to provide adequate pain control.
Choice C reason:
Opioid analgesics, when medically indicated and used under proper medical supervision, rarely cause addiction. The risk of addiction is significantly lower when opioids are used appropriately for pain management in a controlled medical setting. The Mayo Clinic highlights that while opioids have addictive properties, their medical use for pain relief, especially in acute settings, is generally safe when monitored by healthcare professionals.
Choice D reason:
Opioid analgesics are not used only if other measures, such as ice packs, are ineffective. While non-pharmacological measures can be part of pain management, opioids are often necessary for managing severe pain episodes in sickle cell disease. The use of opioids is based on the severity of the pain and the clinical judgment of the healthcare provider.