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:
Extracellular hyperglycemia refers to high blood sugar levels outside the cells. While hyperglycemia is a common feature of diabetic ketoacidosis (DKA), it is not the direct cause of the condition. DKA occurs when the body cannot use glucose for energy due to a lack of insulin, leading to the breakdown of fat and protein for energy, which produces ketones and causes acidosis.
Choice B Reason:
Hypoglycemia, or low blood sugar, is not associated with diabetic ketoacidosis. In fact, DKA is characterized by high blood sugar levels. Hypoglycemia is a separate condition that can occur in individuals with diabetes, particularly if they take too much insulin or skip meals.
Choice C Reason:
The use of fat and protein as an energy source is the primary mechanism behind diabetic ketoacidosis. When insulin is deficient, the body cannot utilize glucose for energy. As a result, it breaks down fat and protein to produce energy. This process generates ketones, which are acidic and lead to the development of ketoacidosis.
Choice D Reason:
Increased cellular metabolism of glucose is not related to diabetic ketoacidosis. In DKA, the problem is that cells cannot use glucose effectively due to a lack of insulin. Instead, the body resorts to breaking down fat and protein for energy, leading to the production of ketones and acidosis.
Correct Answer is B
Explanation
Choice A Reason:
Removing the harness several times a day is not recommended. The Pavlik harness should be worn continuously as prescribed by the doctor to ensure proper hip development. Removing it frequently can disrupt the treatment and may lead to complications.
Choice B Reason:
Placing a superabsorbent disposable diaper over the harness is important to keep the harness clean and dry. This helps prevent skin irritation and maintains hygiene. It is essential to ensure that the diaper is properly positioned to avoid any interference with the harness.
Choice C Reason:
Returning to the clinic every 12 weeks for adjustment of the harness is not accurate. Typically, follow-up visits are more frequent, especially in the initial stages of treatment. Regular adjustments are necessary to ensure the harness is fitting correctly and effectively promoting hip development.
Choice D Reason:
Applying lotion or powder to minimize skin irritation is not recommended. Lotions and powders can accumulate and cause further irritation or infection. Instead, keeping the skin clean and dry is the best way to prevent irritation while using the Pavlik harness.
