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 B
Explanation
Choice A: 50%
If both parents are heterozygous for the sickle cell trait (carriers), each child has a 50% chance of inheriting one sickle cell gene from one parent and a normal gene from the other parent. This would make the child a carrier of the sickle cell trait, not someone with sickle cell anemia. Therefore, the chance of having sickle cell anemia is not 50%.
Choice B: 25%
When both parents are carriers of the sickle cell trait (heterozygous), there is a 25% chance that their child will inherit two sickle cell genes (one from each parent), resulting in sickle cell anemia. This is because each parent has one normal hemoglobin gene (A) and one sickle cell gene (S). The possible combinations for their children are AA (normal), AS (carrier), SA (carrier), and SS (sickle cell anemia). The probability of the SS combination is 25%.
Choice C: 75%
A 75% chance is not accurate in this scenario. The 75% figure might be mistakenly considered if one were to add the probabilities of being a carrier (50%) and having sickle cell anemia (25%). However, these probabilities are distinct and should not be combined in this manner.
Choice D: 100%
A 100% chance would imply that every child of the couple would have sickle cell anemia, which is not the case. Since each parent is a carrier, there is only a 25% chance for each child to have sickle cell anemia. The remaining 75% of the time, the child will either be a carrier or have normal hemoglobin.
Correct Answer is D
Explanation
Choice A reason:
Reducing blood pressure is not a primary management goal for nephrotic syndrome in children. While hypertension can be a complication of nephrotic syndrome, the main focus of treatment is on managing proteinuria, edema, and preventing complications. Blood pressure management may be necessary, but it is not the primary goal.
Choice B reason:
Increasing the excretion of urinary protein is not a desired goal in the management of nephrotic syndrome. In fact, one of the main objectives is to reduce proteinuria (excessive protein in the urine) because it leads to hypoalbuminemia (low levels of albumin in the blood) and edema. Therefore, increasing urinary protein excretion would worsen the condition.
Choice C reason:
Increasing the ability of tissues to retain fluid is not a management goal for nephrotic syndrome. The condition is characterized by edema due to fluid retention, and the goal is to reduce this edema by managing proteinuria and using diuretics if necessary. Therefore, increasing fluid retention would be counterproductive.
Choice D reason:
Reducing the excretion of urinary protein is a primary management goal for nephrotic syndrome1. Proteinuria is a hallmark of the condition, and reducing it helps to alleviate hypoalbuminemia and edema. Treatment often includes corticosteroids to reduce inflammation and protein leakage, as well as other medications to manage symptoms and prevent complications.