A nurse is caring for an adolescent client who is pregnant with their second child and is experiencing anxiety. Which of the following statements should the nurse make?

Rationale:

A. Auscultation: This step is performed after inspection and before percussion or palpation to avoid altering bowel sounds. It allows the nurse to assess for the presence, frequency, and character of bowel sounds without stimulating them artificially.

B. Inspection: This is the first step in the abdominal assessment. It involves visually examining the abdomen for contour, symmetry, skin changes, pulsations, or visible masses without touching the patient, helping establish a baseline.

C. Palpation: Palpation is the final step in abdominal assessment to prevent interference with bowel sounds. It allows the nurse to detect tenderness, masses, or organ enlargement, but should only be done after auscultation and percussion.

D. Percussion: This is done after auscultation and provides information on underlying structures, such as gas, fluid, or masses. It helps differentiate between dullness, resonance, or tympany across abdominal quadrants.

Rationale:

A. “You can obtain a personal response system that will be activated if you fall.": Personal emergency response systems (PERS) allow individuals who live alone to call for help immediately in case of a fall or emergency.

B. “You need to move to a skilled nursing facility where they can prevent falls.": Moving to a skilled nursing facility is a major step and is not necessary solely due to fear of falling. It may also provoke anxiety or feelings of loss of autonomy, especially if less invasive alternatives are available.

C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Daily UAP support may not be realistic or necessary for someone who is still generally independent. This level of care may be excessive unless the client has significant mobility or cognitive impairments.

D. "You should contact a family member once a week to keep in touch.": While weekly contact with family can offer emotional support, it does not provide real-time assistance in the event of a fall. It’s not a sufficient solution for immediate safety concerns.