A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Superficial palpation
Auscultation
Inspection
Deep palpation
The Correct Answer is C, B, A, D
Inspection: This is the first step because it allows the nurse to gather information through observation without causing any discomfort to the child. It involves looking at the child's abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.
Auscultation: After inspection, the nurse listens to the bowel sounds using a stethoscope. This helps assess peristalsis (movement of food through the intestines) and identify potential problems like bowel obstruction or decreased motility.
Superficial Palpation: This gentle palpation helps assess muscle tone, tenderness, and masses. It's performed after auscultation to avoid altering bowel sounds. Since children are often apprehensive about abdominal exams, starting with a gentler touch can help them feel more comfortable.
Deep Palpation (if necessary): Deep palpation is reserved for last as it can be more uncomfortable for the child. It's used to assess for organomegaly (enlarged organs) or masses that may not be palpable with superficial palpation. It's only performed if there are indications from the first three steps.
Here's a breakdown of why this order is important:
Minimize Discomfort: Starting with non-invasive methods like inspection and auscultation helps establish trust and reduces anxiety in the child, making the overall assessment more cooperative.
Maintain Baseline Bowel Sounds: Palpation can alter bowel sounds, so it's important to listen to them first to get an accurate baseline.
Gradual Progression: Moving from gentle to deeper palpation allows the child to adjust to the sensation and helps the nurse identify potential areas of tenderness before applying deeper pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["175"]
Explanation
We are asked to calculate the dosage of cephazolin for a 1-month-old infant based on their weight.
Steps to solve: 1. Identify the given values:
- Dose per kg = 50 mg/kg
- Weight of the infant = 3500 g
2. Set up the formula: Dosage (mg) = Dose per kg (mg/kg) × Weight (kg)
3. Since the weight is given in grams, convert it to kilograms: 3500 g / 1000 g/kg = 3.5 kg
4. Substitute the known values into the formula and calculate: Dosage (mg) = 50 mg/kg × 3.5 kg Dosage (mg) = 175 mg
5. Round the answer to the nearest tenth: Dosage (mg) = 175.0 mg
The nurse should administer 175.0 mg of cephazolin per dose.
Correct Answer is C
Explanation
A. Take the medication with dairy products to increase absorption: Calcium carbonate antacids should not be taken with dairy products as they can reduce the absorption of calcium due to the formation of insoluble calcium salts. It's recommended to take calcium carbonate antacids between meals or with a light snack, but not with dairy products.
B. Decrease bulk in the diet to counteract the adverse effect of diarrhea: Calcium carbonate antacids can sometimes cause constipation rather than diarrhea. Increasing dietary fiber and fluid intake may help prevent constipation associated with the use of these antacids. Therefore, advising to decrease bulk in the diet is not appropriate.
C. Draw a glass of water after taking the medication: Calcium carbonate antacids should be taken with a full glass of water to ensure proper dissolution in the stomach and to prevent the risk of gastrointestinal irritation or obstruction. Water helps facilitate the dissolution and absorption of the medication, reducing the risk of adverse effects.
D. Reduce sodium intake: Calcium carbonate antacids may contain sodium, but reducing sodium intake is not a specific recommendation related to taking this medication. However, it's generally advisable to limit sodium intake for overall health, especially for individuals with conditions such as hypertension or heart failure.
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