A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Percuss all four quadrants of the abdomen to measure sound quality.
Provide adequate lighting to inspect the abdomen.
Listen to the abdominal arteries using the bell of a stethoscope.
Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen.
Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.
The Correct Answer is B, C, E, D, A
B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.
C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.
E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.
D.Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
A blood glucose level of 110 mg/dl: A slightly elevated blood glucose level could be expected in response to enteral feeding.
Choice B reason:
Diarrhea one time in a 24-hour period is incorrect. Diarrhea can occur as a side effect of enteral feeding due to changes in the digestive process.
Choice C reason:
An unexpected finding when a client is receiving continuous enteral feeding via an NG tube is a rapid and significant weight gain of 0.91 kg (2 lb) in just 2 days. This could indicate fluid overload, which might be caused by excessive fluid intake or inadequate fluid removal by the body. Rapid weight gain should be assessed and reported as it could be a sign of underlying issues that need to be addressed.
Choice D reason:
A gastric residual of 300 mL at the end of the shift is incorrect. Gastric residuals can fluctuate during continuous enteral feeding, and a residual of 300 mL may not necessarily be unexpected depending on the client's overall condition and the healthcare provider's guidelines.
Correct Answer is A
Explanation
Choice A reason:
Increased night-time sleeping is the appropriate finding. As individuals age, it is common for their sleep patterns to change. Older adults often experience changes in their sleep duration, including increased night-time sleeping and daytime napping. This can be attributed to changes in circadian rhythm and other factors.
Choice B reason:
A heightened sense of pain is incorrect. Older adults may experience a decreased sensitivity to pain, known as hypoalgesia, due to changes in the nervous system.
Choice C reason:
Decreased sense of balance is incorrect. While changes in balance can occur with aging, they are not universal. Many older adults maintain good balance through exercise and other strategies.
Choice D reason:
Night-time urinary incontinence is incorrect. While some older adults may experience night-time urinary incontinence, it is not a universally expected finding and can be influenced by various factors, including overall health and lifestyle.
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