A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

Auscultation

Inspection

Palpation

Percussion

Answer and Explanation

The Correct Answer is B, A, D, C

B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.

A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.

D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.

C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.

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Correct Answer is D

Explanation

A. Calories is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate calories to prevent malnutrition and weight loss due to inflammation, malabsorption, and increased metabolic rate.

B. Protein is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate protein to promote tissue healing and prevent protein-losing enteropathy.

C. Potassium is incorrect. Clients with Crohn's disease and enteroenteric fistula are at risk of hypokalemia due to diarrhea, vomiting, and fistula drainage. They need to increase their potassium intake to prevent electrolyte imbalance and cardiac complications.

D. Fiber is correct. Clients with Crohn's disease and enteroenteric fistula should decrease their fiber intake to reduce intestinal motility, bulk, and gas production, which can worsen the inflammation and fistula formation.

A. The client reports a decrease in episodes of nausea. B. The client reports a decrease in breast tenderness. C. The client reports a decrease in headaches. D. The client reports a decrease in urinary frequency.

Correct Answer is A

Explanation

A is correct because ginger tea is an herbal remedy that has been shown to reduce nausea and vomiting in pregnancy.

B is incorrect because ginger tea does not have any effect on breast tenderness, which is a common symptom of pregnancy caused by hormonal changes.

C is incorrect because ginger tea does not have any effect on headaches, which can be caused by various factors such as dehydration, stress, or caffeine withdrawal in pregnancy.

D is incorrect because ginger tea does not have any effect on urinary frequency, which is a common symptom of pregnancy caused by increased blood volume and pressure on the bladder.

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A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

Nursing Test Bank

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