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:
Foster self-care activities: Encouraging self-care activities is important for children with hemiplegic cerebral palsy as it promotes independence and self-esteem. However, it is not the highest priority compared to ensuring the child’s safety and accessibility in their home environment.
Choice B Reason:
Improve the child’s communication skills: Enhancing communication skills is crucial for the child’s social and emotional development. Effective communication can significantly improve the child’s quality of life. However, while important, it is not the most immediate priority compared to modifying the home environment for safety.
Choice C Reason:
Modify the home environment for safety and accessibility: Ensuring the home environment is safe and accessible is the top priority. Children with hemiplegic cerebral palsy may have mobility challenges, and a safe environment can prevent injuries and promote independence. This modification directly impacts the child’s daily life and overall well-being.
Choice D Reason:
Provide respite services for the parents: Offering respite services is beneficial for the parents’ mental and emotional health, allowing them to take breaks and recharge. While this is important, it is not the primary concern compared to the child’s immediate safety and accessibility needs.
Correct Answer is D
Explanation
Choice A Reason:
Releasing traction every hour to perform skin care: Releasing traction every hour is not recommended as it can disrupt the alignment and healing process of the fractured femur. Skin care is important, but it should be performed without compromising the traction setup.
Choice B Reason:
Releasing traction once every 8 hours to check circulation: While checking circulation is crucial, releasing traction every 8 hours is not necessary and can interfere with the therapeutic benefits of traction. Circulation can be monitored without releasing the traction.
Choice C Reason:
Maintaining continuous traction until 1 hour before the scheduled surgery: Continuous traction is essential to maintain the alignment of the fractured femur. However, there is no need to release traction 1 hour before surgery unless specifically instructed by the surgical team.
Choice D Reason:
Maintaining continuous traction and checking the position of traction: This is the most appropriate action. Continuous traction ensures proper alignment and healing of the fractured femur. Regularly checking the position of traction helps prevent complications and ensures the effectiveness of the treatment.