A nurse is caring for a client who is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?

Choice A reason: Percussion precedes palpation to assess abdominal resonance and organ size without altering bowel motility. Performing it last risks inaccurate findings, as palpation may stimulate peristalsis, changing resonance patterns. This sequence ensures reliable detection of abnormalities like organomegaly or fluid accumulation in the abdomen.
Choice B reason: Auscultation is done before palpation to capture natural bowel sounds. Manipulation during palpation can alter peristalsis, affecting auscultatory findings. Early auscultation ensures accurate detection of hypoactive or hyperactive bowel sounds, critical for diagnosing conditions like ileus or obstruction in abdominal assessments.
Choice C reason: Palpation is the final step, following inspection, auscultation, and percussion, to assess for tenderness or masses. This sequence prevents manipulation from altering earlier findings, ensuring accurate identification of abdominal abnormalities like peritonitis or organ enlargement, critical for a comprehensive physical examination.
Choice D reason: Inspection is the first step, providing a visual baseline of abdominal appearance, such as distension or scars. Performing it last misses initial cues guiding subsequent steps. Early inspection ensures no manipulation affects visual assessment, vital for identifying external signs of underlying abdominal pathology.

Choice A reason: Using a cane provides stability and reduces fall risk for clients with multiple sclerosis, who often experience muscle weakness or balance issues. This assistive device promotes safe mobility, aligning with evidence-based safety strategies, making it the correct precaution for home care.
Choice B reason: Walking with feet close together decreases stability, increasing fall risk in multiple sclerosis due to impaired coordination. A wider stance is recommended for balance, making this precaution incorrect and potentially dangerous for the client’s safety.
Choice C reason: Avoiding orthotics is not advisable, as they can support mobility and prevent foot drop in multiple sclerosis. Orthotics improve safety and function, so discouraging their use is counterproductive, making this an incorrect recommendation for home safety.
Choice D reason: A rigorous range-of-motion exercise plan may cause fatigue or injury in multiple sclerosis, where moderated exercise is preferred. Overexertion exacerbates symptoms, so this plan is unsafe and inappropriate, making it incorrect for promoting client safety.