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","C","D"]
Explanation
Choice A reason:
Assessing skin turgor underneath the cast is not feasible because the cast covers the skin, making it difficult to evaluate turgor directly. Skin turgor is typically assessed to determine hydration status, but it is not a primary concern when monitoring a child with a cast. The focus should be on assessing for signs of complications such as swelling, circulation issues, and pain.
Choice B reason:
Skin temperature is an important assessment when a child has a cast. Changes in skin temperature, such as increased warmth, can indicate infection or inflammation, while a cooler temperature may suggest compromised circulation. Regularly checking the skin temperature around the cast can help identify potential complications early.
Choice C reason:
Assessing pulses is crucial when a child has a cast. Checking the pulses distal to the cast (e.g., in the fingers or toes) helps ensure that there is adequate blood flow to the extremity. Diminished or absent pulses can indicate compromised circulation, which requires immediate medical attention to prevent tissue damage.
Choice D reason:
Pain assessment is essential for a child with a cast. Pain can be an indicator of complications such as pressure sores, infection, or compartment syndrome. Monitoring the child’s pain levels and addressing any complaints of pain promptly is important for their comfort and to prevent further issues.
Correct Answer is C
Explanation
Choice A: Diffuse fibrin deposition in the microvasculature
Diffuse fibrin deposition in the microvasculature is not characteristic of immune thrombocytopenia (ITP). This description is more aligned with disseminated intravascular coagulation (DIC), a condition where widespread clotting occurs within the blood vessels, leading to multiple organ damage.
Choice B: Deficiency in the production rate of globin chains
A deficiency in the production rate of globin chains is associated with thalassemia, a genetic blood disorder that affects the production of hemoglobin. This is not related to the pathology of immune thrombocytopenia.
Choice C: An excessive destruction of platelets
An excessive destruction of platelets is the hallmark of immune thrombocytopenia (ITP). In ITP, the immune system mistakenly targets and destroys platelets, which are essential for blood clotting. This leads to a low platelet count and an increased risk of bleeding.
Choice D: Bone marrow failure in which all elements are suppressed
Bone marrow failure in which all elements are suppressed is characteristic of aplastic anemia, a condition where the bone marrow fails to produce sufficient blood cells. This is not related to immune thrombocytopenia.