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 B
Explanation
A. Positive Skin Hypersensitivity Test: This is incorrect as it typically involves pain or discomfort with light touch, unrelated to rebound tenderness.
B. Positive Rovsing Sign: A positive Rovsing sign occurs when pain is felt in the right lower quadrant upon palpation of the left lower quadrant, indicating possible appendicitis.
C. Psoas Sign: This is elicited by extending the hip, and a positive sign indicates irritation of the iliopsoas muscle, often seen in appendicitis.
D. Positive Obturator Sign: This involves internal rotation of the hip, also used in appendicitis assessments but involves different positioning.
Correct Answer is ["A","C","D"]
Explanation
A. The client has legal authority to do so: The nurse’s signature confirms that the client appears to have the legal capacity to consent.
B. The client does not have a mental health condition: This is not within the nurse’s purview to assess unless explicitly stated; mental capacity, not condition, is key.
C. The client was not coerced: The nurse’s signature also indicates the consent was given voluntarily, without coercion.
D. The client signed in the nurse's presence: The nurse’s signature confirms that the nurse witnessed the client’s signature.
E. The client speaks the same language as the nurse: Consent requires understanding, which can be provided through an interpreter, so this is not necessary.