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:
Reducing blood pressure is not a primary management goal for nephrotic syndrome in children. While hypertension can be a complication of nephrotic syndrome, the main focus of treatment is on managing proteinuria, edema, and preventing complications. Blood pressure management may be necessary, but it is not the primary goal.
Choice B reason:
Increasing the excretion of urinary protein is not a desired goal in the management of nephrotic syndrome. In fact, one of the main objectives is to reduce proteinuria (excessive protein in the urine) because it leads to hypoalbuminemia (low levels of albumin in the blood) and edema. Therefore, increasing urinary protein excretion would worsen the condition.
Choice C reason:
Increasing the ability of tissues to retain fluid is not a management goal for nephrotic syndrome. The condition is characterized by edema due to fluid retention, and the goal is to reduce this edema by managing proteinuria and using diuretics if necessary. Therefore, increasing fluid retention would be counterproductive.
Choice D reason:
Reducing the excretion of urinary protein is a primary management goal for nephrotic syndrome1. Proteinuria is a hallmark of the condition, and reducing it helps to alleviate hypoalbuminemia and edema. Treatment often includes corticosteroids to reduce inflammation and protein leakage, as well as other medications to manage symptoms and prevent complications.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason:
Jaundice can be an assessment finding in infants with a urinary tract infection (UTI). UTIs can cause systemic symptoms in infants, including jaundice, especially in newborns. This is due to the immature liver function and the body’s response to infection1. Jaundice in the context of a UTI requires prompt medical evaluation and treatment to prevent complications.
Choice B reason:
Failure to gain weight is another possible assessment finding in infants with a UTI. Infants with UTIs may experience poor feeding, irritability, and lethargy, which can contribute to inadequate weight gain2. Monitoring an infant’s growth and development is crucial, and any signs of failure to thrive should prompt further investigation for underlying conditions such as UTIs.
Choice C reason:
Swelling of the face is not typically associated with UTIs in infants. While facial swelling can be a sign of other medical conditions, it is not a common symptom of UTIs. UTIs primarily affect the urinary system and may cause symptoms such as fever, irritability, and poor feeding.
Choice D reason:
Persistent diaper rash can be an assessment finding in infants with a UTI. The presence of a UTI can lead to increased urine output and changes in urine composition, which can irritate the skin and contribute to diaper rash. Persistent or recurrent diaper rash in conjunction with other symptoms may warrant further evaluation for a UTI.
Choice E reason:
Vomiting is a common symptom in infants with UTIs. The infection can cause gastrointestinal symptoms such as vomiting, diarrhea, and poor feeding. These symptoms, along with fever and irritability, are often seen in infants with UTIs and should prompt medical evaluation.