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"]
Explanation
Choice A: Increase Sodium Intake
Increasing sodium intake is generally not recommended for patients with renal disorders. High sodium intake can lead to fluid retention, hypertension, and worsening of kidney function. Patients with renal disorders are often advised to follow a low-sodium diet to manage these risks.
Choice B: Monitor Intake/Output
Monitoring intake and output (I/O) is crucial for patients with renal disorders. It helps in assessing kidney function and fluid balance. Accurate measurement of fluid intake and urine output can provide valuable information about the patient’s hydration status and kidney function. This intervention is essential for preventing fluid overload and dehydration.
Choice C: Daily Weights
Daily weights are an important intervention for patients with renal disorders. Monitoring weight daily helps in detecting fluid retention early. Sudden weight gain can indicate fluid overload, which is a common issue in patients with kidney problems. By tracking daily weights, healthcare providers can make timely adjustments to the patient’s treatment plan.
Choice D: Monitor Blood Pressure
Monitoring blood pressure is a key intervention for patients with renal disorders. Hypertension is both a cause and a consequence of kidney disease. Regular monitoring of blood pressure helps in managing hypertension and preventing further damage to the kidneys. It also aids in assessing the effectiveness of antihypertensive medications.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason:
Using a straw to administer ferrous sulfate is recommended to prevent staining of the teeth. Ferrous sulfate, especially in liquid form, can cause discoloration of the teeth if it comes into direct contact with them. By using a straw, the medication bypasses the teeth, reducing the risk of staining.
Choice B reason:
Giving ferrous sulfate with vitamin C is beneficial because vitamin C enhances the absorption of iron. Vitamin C (ascorbic acid) helps convert iron into a form that is more easily absorbed by the body. Therefore, administering ferrous sulfate with a source of vitamin C, such as orange juice, can improve its effectiveness.
Choice C reason:
It is best to give ferrous sulfate with food to reduce gastrointestinal side effects. While iron is best absorbed on an empty stomach, it can cause stomach upset, nausea, and constipation. Taking the medication with food can help mitigate these side effects, making it more tolerable for the child.
Choice D reason:
Giving ferrous sulfate with milk is not recommended. Dairy products, including milk, can interfere with the absorption of iron. Calcium in milk binds with iron, reducing its bioavailability and effectiveness. Therefore, it is best to avoid giving ferrous sulfate with milk or other dairy products.