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:
A low-fat, low-carbohydrate diet is not specifically recommended for children with acute glomerulonephritis. The primary dietary concern for these children is managing fluid retention and blood pressure, which is more directly influenced by salt intake rather than fat or carbohydrate intake.
Choice B Reason:
Decreasing the number of calories in the child’s diet is not a primary recommendation for managing acute glomerulonephritis. While maintaining a healthy weight is important, the focus should be on reducing salt intake to manage edema and blood pressure.
Choice C Reason:
Avoiding salt is crucial for children with acute glomerulonephritis. Salt can lead to water retention, which exacerbates edema and can increase blood pressure. Therefore, it is important to limit salt intake to help manage these symptoms.
Choice D Reason:
Increasing the amount of protein in the diet is not recommended for children with acute glomerulonephritis. In fact, protein intake may need to be limited because the kidneys are less able to filter waste products from protein metabolism. Excessive protein can put additional strain on the kidneys.
Correct Answer is D
Explanation
Choice A reason:
The musculoskeletal system is not primarily affected by abnormal phenylalanine levels. Phenylketonuria (PKU) is a metabolic disorder that primarily impacts the brain and cognitive functions. While muscle weakness can occur due to overall health deterioration, it is not the primary system affected by phenylalanine toxicity.
Choice B reason:
The renal system is not the main target of phenylalanine toxicity. Although the kidneys play a role in filtering blood and excreting waste, the toxic effects of phenylalanine accumulation are more pronounced in the brain. Therefore, the renal system is not the primary system affected by abnormal phenylalanine levels.
Choice C reason:
The GI system, or gastrointestinal system, is not the primary system affected by abnormal phenylalanine levels. While dietary management is crucial for individuals with PKU to control phenylalanine intake, the toxic effects are primarily seen in the brain. The GI system is involved in the absorption and digestion of nutrients, but it is not the main system impacted by phenylalanine toxicity.
Choice D reason:
The central nervous system (CNS) is the primary system affected by abnormal phenylalanine levels. Phenylketonuria (PKU) leads to the accumulation of phenylalanine in the brain, causing severe brain damage and cognitive impairments. High levels of phenylalanine can disrupt neurotransmitter synthesis and brain development, leading to intellectual disabilities and other neurological issues. Therefore, the CNS is the main system impacted by phenylalanine toxicity.