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
While some children may pull their ears when they have a cold, it is not a definitive sign of acute nasopharyngitis. Ear pulling can also indicate other issues such as ear infections.
Choice B rationale
Antibiotics are not typically prescribed for acute nasopharyngitis, as it is usually caused by a viral infection. Antibiotics are only used if there is a secondary bacterial infection.
Choice C rationale
Healthy children can have multiple colds per year, especially if they are exposed to other children in settings like daycare or school. It is not uncommon for children to have several colds annually.
Choice D rationale
A cough that accompanies a cold should not be suppressed as it helps clear mucus from the airways. Suppressing the cough can lead to mucus buildup and potential complications.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Oxygen saturation of 88% on room air is significantly below the normal range (95-100%) and indicates hypoxemia. This finding should be reported to the provider as it may require supplemental oxygen or other interventions.
Choice B rationale:
A heart rate of 128/min is elevated for a school-age child and may indicate increased work of breathing, fever, or other underlying issues. This finding should be reported to the provider for further evaluation.
Choice C rationale:
While the child reporting chest discomfort as 4 on a scale of 0 to 10 is important, it is not as critical as the other findings. The provider should be aware of the discomfort, but it may not require immediate intervention.
Choice D rationale:
An elevated WBC count of 15,000/mm³ indicates an infection, which is consistent with the diagnosis of bilateral pneumonia. While this is important information, it is expected in the context of the current diagnosis and may not require immediate reporting.
Choice E rationale:
Passing three large, frothy, foul-smelling stools is significant in a child with cystic fibrosis as it may indicate malabsorption or other gastrointestinal issues. This finding should be reported to the provider for further evaluation and potential adjustment of the treatment plan.
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