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 B
Explanation
Choice A reason:
Hypokalemia, or low potassium levels, is not typically associated with chronic renal failure. In fact, chronic renal failure often leads to hyperkalemia, which is an elevated level of potassium in the blood. This occurs because the kidneys are unable to excrete potassium effectively, leading to its accumulation in the body. Therefore, hypokalemia is not a clinical manifestation of chronic renal failure.
Choice B reason:
Oliguria, or reduced urine output, is a common clinical manifestation of chronic renal failure2. As the kidneys lose their ability to filter and excrete waste products, urine production decreases. This reduction in urine output is a key indicator of declining kidney function and is often observed in children with chronic renal failure. Monitoring urine output is crucial in assessing the progression of the disease and the effectiveness of treatment.
Choice C reason:
Hypotension, or low blood pressure, is not typically seen in chronic renal failure. Instead, hypertension, or high blood pressure, is more commonly associated with chronic renal failure. The kidneys play a crucial role in regulating blood pressure, and when they are not functioning properly, it can lead to an increase in blood pressure. Therefore, hypotension is not a clinical manifestation of chronic renal failure.
Choice D reason:
Massive hematuria, or the presence of a large amount of blood in the urine, is not a typical clinical manifestation of chronic renal failure. While hematuria can occur in some kidney conditions, it is not a defining feature of chronic renal failure. Chronic renal failure is more commonly associated with symptoms such as oliguria, fatigue, and swelling due to fluid retention.
Correct Answer is C
Explanation
Choice A reason:
A diet consisting of low-fat, low-carbohydrate foods is not specifically recommended for managing severe edema associated with acute glomerulonephritis. While a balanced diet is important, the primary dietary focus should be on reducing sodium intake to prevent fluid retention and manage edema. Therefore, this choice is not the most appropriate recommendation.
Choice B reason:
Decreasing the number of calories in the child’s diet is not a primary recommendation for managing severe edema associated with acute glomerulonephritis. The focus should be on reducing sodium intake rather than calorie restriction. Adequate nutrition is essential for the child’s overall health and recovery1. Therefore, this choice is not the most appropriate recommendation.
Choice C reason:
Avoiding adding salt to the child’s food is a key recommendation for managing severe edema associated with acute glomerulonephritis. Sodium can lead to water retention, which can worsen edema and increase blood pressure. A low-sodium diet helps to reduce fluid retention and manage the symptoms of glomerulonephritis. This is the most appropriate dietary recommendation for managing severe edema in this condition.
Choice D reason:
Increasing the amount of protein in the child’s diet is not recommended for managing severe edema associated with acute glomerulonephritis1. In fact, protein intake may need to be monitored and possibly restricted to prevent the buildup of waste products in the blood1. The primary dietary focus should be on reducing sodium intake to manage edema. Therefore, this choice is not the most appropriate recommendation.