Select the sequence of techniques used during an examination of the abdomen.
Percussion, inspection, palpation, auscultation.
Inspection, palpation, percussion, auscultation.
Inspection, auscultation, percussion, palpation.
Auscultation, inspection, palpation, percussion.
The Correct Answer is C
A. Percussion, inspection, palpation, auscultation: This sequence could disturb bowel sounds by percussing before auscultation, making it difficult to assess them accurately.
B. Inspection, palpation, percussion, auscultation: Palpating before auscultating can alter bowel sounds, so it’s not the correct order.
C. Inspection, auscultation, percussion, palpation: This sequence is recommended for abdominal assessment to avoid altering bowel sounds. Inspection is done first to observe any visible abnormalities, followed by auscultation to listen to bowel sounds before palpating or percussing, which could disrupt the sounds.
D. Auscultation, inspection, palpation, percussion: Inspection should always be first, making this option incorrect as it begins with auscultation.
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Correct Answer is C
Explanation
A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.
B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.
C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.
D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.
Correct Answer is C
Explanation
A. The client is terminally ill: DPOA is not automatically activated by terminal illness but by the client’s inability to communicate.
B. The client is incapable of providing self-care: This alone does not activate the DPOA unless they are also unable to make healthcare decisions.
C. The client is unable to express their wishes: Durable power of attorney for healthcare decisions is activated when the client becomes unable to make or communicate their healthcare choices.
D. The client has refused treatment: Refusal of treatment is a decision that an alert and capable client can make independently.