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 B

Explanation

A. Liver function tests: While lithium can affect liver function in some cases, routine liver function tests are not typically required before administering lithium. These tests are more relevant for medications metabolized by the liver.
B. Thyroid hormone assay: This is the correct action. Regular monitoring of thyroid function, including thyroid hormone levels, is essential for clients taking lithium, as lithium therapy can lead to hypothyroidism or exacerbate preexisting thyroid conditions. Checking thyroid function before administering lithium helps ensure the client's thyroid status is within the therapeutic range and identifies any abnormalities that may require intervention.
C. Erythrocyte sedimentation rate (ESR): ESR is a nonspecific marker of inflammation and is not directly relevant to monitoring lithium therapy. While lithium can affect renal function and electrolyte balance, ESR does not specifically assess these parameters.
D. Brain natriuretic peptide (BNP): BNP is a marker of cardiac function and is not routinely monitored in clients taking lithium. While lithium can have cardiovascular effects, routine BNP testing is not necessary before administering lithium. Monitoring for cardiovascular side effects of lithium typically involves assessing for symptoms such as arrhythmias or changes in blood pressure and heart rate.

A. BP B. Weight C. Heart rate D. Urine output

Correct Answer is C

Explanation

A. BP (Blood Pressure): While monitoring blood pressure is important in assessing fluid status, a decrease in blood pressure may indicate inadequate fluid resuscitation rather than adequate replacement. Hypotension may suggest ongoing hypovolemia and the need for further fluid administration.
B. Weight: Weight may provide information about fluid balance over time, but it is not an immediate indicator of adequate fluid replacement during resuscitation. Changes in weight may lag behind changes in fluid status and may not reflect real-time fluid needs.
C. Heart rate: During fluid resuscitation for severe burn injuries, one of the primary goals is to restore intravascular volume and cardiac output. As fluid replacement improves, the heart rate typically decreases, reflecting improved perfusion and reduced sympathetic response.
D. Urine output: Urine output is another critical parameter to monitor during fluid resuscitation, but a decrease in urine output could indicate inadequate fluid replacement rather than adequate replacement.

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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

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A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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