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 ["A","B","C","E"]
Explanation
Choice A reason:
A positive Ortolani click is a clinical manifestation of developmental dysplasia of the hip (DDH). The Ortolani maneuver is used to detect hip dislocation or subluxation in infants. When the hip is abducted and gentle pressure is applied to the proximal thigh from behind, a palpable “clunk” is noticed as the femoral head relocates into the acetabulum. This indicates hip instability, which is a characteristic of DDH.
Choice B reason:
Unequal gluteal folds are another clinical manifestation of DDH. Asymmetrical gluteal creases can suggest hip dysplasia in infants. This is because the dislocation or subluxation of the hip can cause one leg to appear shorter than the other, leading to uneven gluteal folds.
Choice C reason:
The Trendelenburg sign is a clinical test used to assess the integrity and strength of the hip abductor muscles, particularly the gluteus medius and gluteus minimus. A positive Trendelenburg sign usually indicates weakness in these muscles, which can be associated with hip abnormalities such as congenital hip dislocation3. In DDH, the hip instability can lead to a positive Trendelenburg sign.
Choice D reason:
A negative Babinski sign is not a clinical manifestation of DDH. The Babinski reflex is a normal reflex in infants up to 2 years old, where the big toe moves upward and the other toes fan out when the sole of the foot is stroked. A negative Babinski sign would indicate the absence of this reflex, which is not related to DDH.
Choice E reason:
Telescoping of the affected limb is a clinical manifestation of DDH. In a child with DDH, the hip socket is shallow, and the head of the femur may slip in and out, leading to a telescoping effect. This means the femoral head can move further out of the socket, causing the limb to appear shorter or longer depending on the position.
Correct Answer is B
Explanation
Choice A reason:
Bacteriuria, or the presence of bacteria in the urine, is not typically associated with acute glomerulonephritis. Acute glomerulonephritis is primarily an inflammatory condition affecting the glomeruli of the kidneys, and it does not usually involve bacterial infection. Increased specific gravity can occur due to concentrated urine, but bacteriuria is not a characteristic finding.
Choice B reason:
Hematuria, or blood in the urine, and mild to moderate proteinuria are characteristic findings in acute glomerulonephritis. Hematuria occurs due to inflammation and damage to the glomeruli, allowing red blood cells to pass into the urine. Proteinuria results from the increased permeability of the glomerular basement membrane, allowing proteins to leak into the urine. These findings are key indicators of glomerular inflammation and damage.
Choice C reason:
While proteinuria can be present in acute glomerulonephritis, bacteriuria is not a typical finding. The condition is primarily inflammatory rather than infectious, so the presence of bacteria in the urine is not expected. The focus should be on the inflammatory markers such as hematuria and proteinuria.
Choice D reason:
High levels of proteinuria and decreased specific gravity are not typical findings in acute glomerulonephritis. While proteinuria can occur, it is usually mild to moderate rather than high. Specific gravity may be increased due to concentrated urine, but decreased specific gravity is not a characteristic finding of this condition.
