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 C
Explanation
Choice A reason:
Measuring the abdominal girth is a useful assessment tool in cases of suspected abdominal distension or fluid accumulation. However, in the context of intussusception, the passage of a currant jelly-like stool is a more critical indicator of the condition. While measuring abdominal girth can provide additional information, it is not the most appropriate immediate action in this scenario.
Choice B reason:
Notifying the practitioner as this is not a typical finding is incorrect because the passage of currant jelly-like stool is a classic symptom of intussusception. This stool appearance results from a mixture of mucus and blood due to the telescoping of the intestine, which compromises blood flow and causes ischemia. Therefore, this finding should be documented as expected rather than considered atypical.
Choice C reason:
Documenting the passage of currant jelly-like stool as an expected finding and planning to move forward with the procedure is the most appropriate action. This stool appearance is a hallmark sign of intussusception, indicating that the condition is present and needs to be addressed promptly. The radiologist-guided pneumoenema is a diagnostic and therapeutic procedure that can help resolve the intussusception by using air pressure to unfold the telescoped segment of the intestine. Therefore, documenting this finding and proceeding with the planned intervention is crucial.
Choice D reason:
Auscultating for bowel sounds is a standard nursing assessment technique to evaluate gastrointestinal function. However, in the context of intussusception, the passage of currant jelly-like stool is a more definitive indicator of the condition. While auscultating for bowel sounds can provide additional information about bowel activity, it is not the most appropriate immediate action in this scenario.
Correct Answer is D
Explanation
Choice A reason:
A 7-year-old child with diabetes insipidus and a urine specific gravity of 1.016 is not in immediate danger. Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of severely diluted urine. A urine specific gravity of 1.016 is within the normal range (1.005 to 1.030). Therefore, this child does not require immediate assessment.
Choice B reason:
A 4-year-old child with asthma and a PCO2 of 37 mm Hg is also not in immediate danger. Asthma is a chronic condition that can cause difficulty breathing, but a PCO2 level of 37 mm Hg is within the normal range (35-45 mm Hg). This indicates that the child’s respiratory status is currently stable, and immediate assessment is not required.
Choice C reason:
A 1-year-old toddler with roseola and a temperature of 39°C (102.2°F) is experiencing a common viral infection that typically causes a high fever followed by a rash. While the fever is high, it is not uncommon for roseola and can be managed with antipyretics and supportive care. This child does not require immediate assessment.
Choice D reason:
A 10-year-old child with sickle cell anemia reporting 8 out of 10 chest pain is in immediate danger and requires urgent assessment. Chest pain in a child with sickle cell anemia can indicate acute chest syndrome, a severe and potentially life-threatening complication. Acute chest syndrome is characterized by chest pain, fever, and respiratory distress, and it requires prompt medical intervention. Therefore, this child should be assessed first.