A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Press deeply into the client's upper abdomen left of midline to detect aortic pulsation.
Use fingertips to lightly depress the right lower quadrant of the client's abdomen.
Systematically percuss the client's abdomen.
Observe the contours of the client's abdomen using a penlight
Determine the presence of bowel sounds by using the diaphragm of the stethoscope.
The Correct Answer is D,E,C,B,A
A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.
E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. The nurse's signature confirms that the client signed the informed consent document in the nurse's presence, verifying that the client provided consent voluntarily.
B. The nurse's signature confirms that the client has legal capacity and authority to provide consent for the proposed treatment or procedure.
C. The nurse's signature does not confirm the absence of a mental health condition; rather, it confirms that the client has provided informed consent.
D. The nurse's signature confirms that the client provided consent voluntarily and was not coerced or unduly influenced to do so.
E. While it is important for the client to understand the information provided, the nurse's signature does not specifically confirm this requirement.
Correct Answer is A
Explanation
A. Denial is the first stage of grief, in which the person refuses to accept the reality of their situation and tries to maintain a sense of normalcy. The client who says they are looking forward to seeing their grandchildren grow up is denying the fact that they have a terminal illness and that they may not live long enough to witness that.
B. Bargaining involves making deals with self and God to help feel better, for instance, in this case the client will be expressing the will to do anything to prolong his life.
C. Acceptance involves coming to terms with the reality of the situation and preparing for death. The client's statement does not indicate full acceptance.
D. Anger involves feelings of resentment or frustration. The client's statement does not express anger towards their situation.
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