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:
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.
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.
