A nurse is preparing to perform an abdominal assessment on a child.
Identify the sequence the nurse should follow.
Inspection.
Auscultation.
Superficial palpation.
Deep palpation.
The Correct Answer is A,B,C,D
A. Inspection: This is the first step as it allows the nurse to gather information through observation without causing discomfort to the child. It involves looking at the child’s abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.
B. Auscultation: This step follows inspection to assess bowel sounds before any manipulation of the abdomen, which could alter the sounds. The nurse listens for the presence, frequency, and character of bowel sounds.
C. Superficial palpation: This step is performed to assess for tenderness, muscle tone, and surface characteristics. It is done gently to avoid causing pain or discomfort.
D. Deep palpation: This is the final step to assess for any masses, organomegaly, or deep tenderness. It is performed more firmly but should be done carefully to avoid causing pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Polyuria, or excessive urination, is typically associated with hyperglycemia rather than hypoglycemia. In the context of diabetes, polyuria occurs when high blood glucose levels lead to increased urine production as the body attempts to excrete excess glucose. Since the adolescent’s blood glucose level is 55 mg/dL, which indicates hypoglycemia, polyuria is not an expected finding.
Choice B rationale
Dry, flushed skin is a common symptom of hyperglycemia, not hypoglycemia. When blood glucose levels are high, the body becomes dehydrated, leading to dry skin and a flushed
appearance. In contrast, hypoglycemia often presents with symptoms such as sweating, pallor, and shakiness due to the body’s response to low blood glucose levels.
Choice C rationale
Deep, rapid respirations, also known as Kussmaul respirations, are typically associated with diabetic ketoacidosis (DKA), a complication of hyperglycemia. DKA occurs when the body produces high levels of ketones due to insufficient insulin. Since the adolescent’s blood glucose level is 55 mg/dL, which indicates hypoglycemia, deep, rapid respirations are not an expected finding.
Choice D rationale
Tachycardia, or an increased heart rate, is a common symptom of hypoglycemia. When blood glucose levels drop, the body releases catecholamines (such as adrenaline) to raise blood glucose levels. This response leads to symptoms such as shakiness, sweating, and tachycardia. Therefore, tachycardia is an expected finding in an adolescent with a blood glucose level of 55 mg/dL.
Correct Answer is ["200"]
Explanation
Step 1 is (100 mL ÷ 0.5 hr) = 200 mL/hr. The nurse should set the pump to deliver 200 mL/hr.
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