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 B
Explanation
The correct answer is Choice B.
Choice A rationale
Environment plays a significant role in a child’s growth and development, including factors like socioeconomic status, access to education, and living conditions. However, it can be altered to some extent.
Choice B rationale
Genetics is the largest factor impacting growth and development that cannot be altered. Genetic factors determine physical characteristics, susceptibility to certain diseases, and overall growth patterns.
Choice C rationale
Socialization influences a child’s development, including social skills and behavior. While important, it can be influenced and altered through various interventions.
Choice D rationale
Nutrition is crucial for growth and development, affecting physical and cognitive development. However, it can be modified through dietary changes and interventions.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Testing the urine for ketones is essential for managing type 1 diabetes, especially during illness. Ketones are produced when the body breaks down fat for energy due to insufficient insulin. High levels of ketones can lead to diabetic ketoacidosis, a serious condition that requires immediate medical attention.
Choice B rationale
While notifying the provider if blood glucose levels are over 350 mg/dL is important, it is not the most immediate action required during illness management. High blood glucose levels can indicate poor diabetes control, but ketone testing is more critical during illness to prevent ketoacidosis.
Choice C rationale
Withholding insulin when feeling nauseous is incorrect. Insulin should not be withheld during illness, as blood glucose levels can increase due to stress or infection. Continuing insulin administration is crucial to prevent hyperglycemia and ketoacidosis.
Choice D rationale
Limiting fluid intake during mealtime is not recommended. Proper hydration is essential for overall health and helps manage blood glucose levels. Fluids should be consumed as needed, especially during illness.
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