A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment.
(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Inspect the abdomen for skin integrity.
Ask the client about having a history of abdominal pain.
Auscultate the abdomen for bowel sounds.
Percuss the abdomen in each of the four quadrants.
Palpate the abdomen gently for tenderness.
The Correct Answer is A,B,C,D,E
1. a) Inspect the abdomen for skin integrity: The first step in an abdominal assessment is inspection. The nurse should visually examine the abdomen for any abnormalities such as skin changes, scars, distention, or masses.
2. b) Ask the client about having a history of abdominal pain: Gathering a history of abdominal pain is crucial as it provides context for the physical findings. This step helps identify any underlying conditions that may influence the assessment.
3. c) Auscultate the abdomen for bowel sounds: Auscultation should be performed before palpation and percussion to avoid altering the bowel sounds. The nurse listens for the presence, frequency, and character of bowel sounds in all four quadrants.
4. d) Percuss the abdomen in each of the four quadrants: Percussion helps to assess the presence of fluid, air, or masses in the abdomen. The nurse taps on the abdomen to listen for sounds that indicate the underlying structures.
5. e) Palpate the abdomen gently for tenderness: Palpation is the final step and involves gently pressing on the abdomen to check for tenderness, masses, or organ enlargement. This step should be done last to avoid causing discomfort or altering the findings of the other steps.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Dependent rubor
Dependent rubor is a reddish discoloration of the skin that occurs when the leg is in a dependent position (hanging down). This condition is typically associated with arterial insufficiency rather than chronic venous insufficiency. Arterial insufficiency occurs when there is inadequate blood flow through the arteries, leading to symptoms such as pain, cramping, and changes in skin color. Dependent rubor is a sign of poor arterial circulation and is not commonly seen in venous insufficiency.
Choice B reason: Thick, deformed toenails
Thick, deformed toenails can be a sign of fungal infections or other conditions affecting the nails, but they are not specifically indicative of chronic venous insufficiency. While individuals with chronic venous insufficiency may have poor circulation that can contribute to nail problems, this symptom is not a primary or common finding associated with the condition. Instead, it is more often related to other underlying health issues.
Choice C reason: Hair loss
Hair loss on the legs can occur due to various reasons, including poor circulation. However, it is more commonly associated with arterial insufficiency rather than chronic venous insufficiency. In arterial insufficiency, the reduced blood flow can lead to hair loss, shiny skin, and other changes in the lower extremities. Chronic venous insufficiency primarily affects the veins and leads to symptoms such as swelling, varicose veins, and skin changes.
Choice D reason: Edema
Edema, or swelling, is a hallmark symptom of chronic venous insufficiency. This condition occurs when the veins in the legs are unable to effectively return blood to the heart, leading to blood pooling in the lower extremities. The increased pressure in the veins causes fluid to leak into the surrounding tissues, resulting in swelling. Edema is often more pronounced at the end of the day or after prolonged periods of standing or sitting. Managing edema is a key aspect of treating chronic venous insufficiency, and it often involves the use of compression stockings, elevation of the legs, and other measures to improve venous return.
Correct Answer is B
Explanation
Choice A reason:
Advising that the largest meal of the day should be in the evening is not typically recommended for clients with a colostomy. It is generally better to have smaller, more frequent meals throughout the day to aid digestion and reduce the risk of discomfort.
Choice B reason:
Eating yogurt can indeed help decrease the amount of gas. Yogurt contains probiotics, which can aid in digestion and reduce gas production. This is a beneficial dietary choice for clients with a colostomy.
Choice C reason:
Carbonated beverages are not recommended for controlling odor. In fact, they can increase gas production and lead to bloating, which can be uncomfortable for clients with a colostomy.
Choice D reason:
There is no need to eliminate pasta from the diet to prevent loose stools. Instead, clients should focus on a balanced diet that includes low-fiber foods initially and gradually reintroduce other foods while monitoring their effects.
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