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 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 B
Explanation
Choice A Reason:
Idiopathic scoliosis is not typically noticeable when a toddler begins to walk. At this stage, the spine is still developing, and any curvature is usually not significant enough to be detected. Idiopathic scoliosis most commonly becomes noticeable during periods of rapid growth, which occur later in childhood.
Choice B Reason:
The preadolescent growth spurt is the period when idiopathic scoliosis becomes most noticeable. This is because the rapid growth during this time can exacerbate the curvature of the spine. Idiopathic scoliosis often becomes apparent between the ages of 10 and 18 years, when children experience significant growth spurts.
Choice C Reason:
Late adolescence is not the period when idiopathic scoliosis becomes most noticeable. By this time, most children have completed their major growth spurts, and any scoliosis would likely have been detected earlier. The condition is typically identified during the preadolescent growth spurt.
Choice D Reason:
The newborn period is not associated with the development of idiopathic scoliosis. While congenital scoliosis can be present at birth, idiopathic scoliosis develops later in childhood, particularly during periods of rapid growth.
