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 B
Explanation
Choice A reason:
Adequate oxygenation is important in managing vaso-occlusive sickle cell crisis, but the replacement of factor V is not relevant to this condition. Factor V is involved in the blood clotting process, and its replacement is typically associated with bleeding disorders such as hemophilia. Therefore, this choice is not appropriate for managing a vaso-occlusive crisis.
Choice B reason:
Adequate hydration and pain management are critical components of care for a child in vaso-occlusive sickle cell crisis. Hydration helps to reduce the viscosity of the blood, which can prevent further sickling of red blood cells and improve blood flow. Pain management is essential because vaso-occlusive crises are extremely painful and require prompt and effective pain relief, often with opioid analgesics. These measures help to alleviate symptoms and prevent complications.
Choice C reason:
Pain management is indeed a crucial aspect of care for vaso-occlusive sickle cell crisis, but the administration of heparin is not typically part of the treatment. Heparin is an anticoagulant used to prevent blood clots, and it is not indicated for managing vaso-occlusive crises. The focus should be on hydration and pain relief rather than anticoagulation.
Choice D reason:
Correction of acidosis may be necessary in some cases, but it is not the primary focus of care for vaso-occlusive sickle cell crisis. The main goals are to manage pain and ensure adequate hydration to improve blood flow and reduce the risk of further sickling of red blood cells. While addressing acidosis can be part of the overall management, it is not the primary intervention.