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 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.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason: Waddling gait:
Children with Duchenne muscular dystrophy (DMD) often exhibit a waddling gait due to progressive muscle weakness, particularly in the pelvic girdle muscles. This gait pattern is a compensatory mechanism to maintain balance and mobility despite weakened muscles. The waddling gait is one of the early signs of DMD and typically becomes noticeable between the ages of 2 and 6 years.
Choice B Reason: Kyphosis:
Kyphosis, an excessive outward curvature of the spine, can develop in children with DMD as the disease progresses. Muscle weakness and imbalance, particularly in the back muscles, contribute to this spinal deformity. Kyphosis can lead to discomfort, respiratory issues, and further mobility challenges, necessitating close monitoring and intervention.
Choice C Reason:Lordosis:
Lordosis, an exaggerated inward curvature of the lower spine, is another common finding in children with DMD. This condition often develops as a compensatory mechanism to maintain an upright posture despite weakened hip and thigh muscles. Lordosis can cause lower back pain and impact overall posture and gait.
Choice D Reason:Scoliosis:
Scoliosis, a lateral curvature of the spine, frequently occurs in children with DMD due to progressive muscle weakness and imbalance. As the disease advances, scoliosis can become more pronounced, leading to discomfort, respiratory complications, and further functional limitations. Early detection and management are crucial to mitigate these effects.
Choice E Reason:Gower sign:
The Gower sign is a classic clinical indicator of DMD. It refers to the maneuver children with DMD use to rise from the floor, involving the use of their hands to “walk” up their legs due to proximal muscle weakness. This sign is typically observed in early childhood and is a key diagnostic feature of DMD1.