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

Each statement provides valuable information about the child's behavior or physical condition.

A. "Sometimes my child acts bossy with his friends.": This statement indicates a behavioral characteristic of the child that may be typical for a 6-year-old. While it's essential for the child to learn appropriate social behaviors, occasional bossiness is not unusual at this age and may reflect normal developmental stages.
B. "My child often cheats when we play board games.": While honesty is important, cheating during games is a behavior that some children may exhibit during certain developmental stages. It can provide insight into the child's understanding of rules and social interactions but may not necessarily be a cause for significant concern.
C. "The teacher says my child has to squint to see the board.": This statement raises concern about the child's vision and suggests potential visual impairment or difficulty seeing distant objects clearly. Squinting to see the board could indicate nearsightedness or other vision problems that may require further assessment and intervention by an eye care professional.
D. "My child has recently lost both front top teeth.": Losing baby teeth is a normal developmental milestone for children around the age of 6. It typically indicates the natural process of permanent teeth erupting, and it's not typically a cause for concern unless there are complications or abnormalities associated with tooth loss.

A. "My child must be free from this before returning to school" B. "Toys that can't be dry cleaned or washed must be thrown out." C. "All recently used clothing, bedding, and towels must be washed in hot water" D. "I will treat all the family members to be on the safe side. "

Correct Answer is C

Explanation

A. "My child must be free from this before returning to school": While it's important for the child to be treated and free from head lice before returning to school, this statement alone doesn't address the comprehensive measures needed to eradicate pediculosis capitis. It focuses only on the child's return to school without considering other aspects of treatment and prevention.
B. "Toys that can't be dry cleaned or washed must be thrown out": Throwing out toys that can't be dry cleaned or washed is an extreme measure and unnecessary for managing pediculosis capitis. While cleaning items that come into contact with the child's head is important, it's not necessary to dispose of toys unless they cannot be effectively cleaned.
C. "All recently used clothing, bedding, and towels must be washed in hot water": This statement indicates a thorough understanding of the teaching. Washing recently used clothing, bedding, and towels in hot water is an essential step in eliminating head lice and preventing reinfestation. Hot water helps kill lice and their eggs, reducing the risk of transmission.
D. "I will treat all the family members to be on the safe side": Treating all family members is a prudent measure to prevent the spread of head lice within the household. However, this statement alone doesn't address other important aspects of treatment and prevention, such as washing bedding and clothing. While treating family members is important, it's only one part of a comprehensive approach to managing pediculosis capitis.

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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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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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