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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. This statement reflects guilt or concern over potential harm to the child, which may be distressing but does not specifically indicate symptoms of PTSD related to combat exposure.
B. This statement describes nightmares or intrusive thoughts related to traumatic events, which are common symptoms of PTSD. The content of the dreams suggests re-experiencing of traumatic events, which is characteristic of PTSD.
C. This statement reflects hypervigilance and paranoia, common symptoms of PTSD. The client's behavior of checking rooms for potential threats indicates a heightened state of arousal and persistent fear related to past combat experiences.
D. While involvement in combat and actions such as killing enemy soldiers may contribute to the development of PTSD, this statement does not directly reflect symptoms of the disorder. Instead, it describes a specific event from the client's military experience. Symptoms of PTSD typically involve re-experiencing, avoidance, negative changes in mood and cognition, and hyperarousal.

A. Blood B. Parasites C. Steatorrhea D. Bacteria

Correct Answer is A

Explanation

A. Blood: The purpose of a stool guaiac test is to detect the presence of occult (hidden) blood in the stool. This test is commonly used to screen for gastrointestinal bleeding, which may indicate various conditions such as peptic ulcers, colorectal cancer, inflammatory bowel disease, or hemorrhoids. The guaiac test relies on the chemical reaction between guaiac resin and the heme component of hemoglobin in blood, resulting in a color change when blood is present in the stool.
B. Parasites: Stool tests for parasites typically involve examining stool samples under a microscope to identify the presence of parasitic organisms, such as protozoa or helminths. These tests are used to diagnose parasitic infections, such as giardiasis, cryptosporidiosis, or intestinal worms, rather than detecting blood in the stool.
C. Steatorrhea: Stool tests for steatorrhea assess the presence of excess fat in the stool, which may indicate malabsorption disorders, pancreatic insufficiency, or other gastrointestinal conditions affecting fat digestion and absorption. These tests involve analyzing stool samples for the presence of undigested fat globules rather than detecting blood.
D. Bacteria: Stool cultures are used to detect the presence of pathogenic bacteria in the stool, which may indicate bacterial infections such as Salmonella, Shigella, or Campylobacter. These tests involve culturing stool samples on specific media to identify bacterial pathogens rather than detecting blood. Stool guaiac tests specifically target the detection of occult blood and are not designed to identify bacteria in the stool.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Correct Answer is A

Explanation

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

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