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 A
Explanation
Choice A Reason:
Cleansing the suture line, maintaining an upright position, and using arm restraints are crucial aspects of postoperative care for an infant after cleft lip repair. Cleansing the suture line helps prevent infection and promotes healing. Keeping the infant in an upright position reduces the risk of aspiration and helps with breathing. Arm restraints prevent the infant from touching or rubbing the surgical site, which could disrupt the healing process.
Choice B Reason:
Mouth irrigations and a prone position are not recommended for postoperative care after cleft lip repair. Mouth irrigations can be too harsh for the delicate surgical site, and a prone position (lying face down) can increase the risk of aspiration and breathing difficulties. Cleansing the suture line is important, but the other aspects of this choice are not suitable.
Choice C Reason:
Frequent oral suction and spoon feeding are not appropriate for an infant after cleft lip repair. Oral suction can be too aggressive and may damage the surgical site. Spoon feeding is not recommended as it can put pressure on the healing lip. Giving a teething toy is also not advisable as it can cause the infant to put objects in their mouth, potentially harming the surgical site.
Choice D Reason:
Arm restraints are indeed necessary to prevent the infant from touching the surgical site. However, postural drainage and mouth irrigations are not suitable for postoperative care after cleft lip repair. Postural drainage is not relevant to this condition, and mouth irrigations can be too harsh for the healing tissue.
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.