A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Deep palpation
Light palpation
Auscultation
Inspection
The Correct Answer is D,C,B,A
Rationale:
D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.
C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.
B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.
A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Nystagmus: Nystagmus is characterized by involuntary eye movements and is typically associated with vestibular disorders, multiple sclerosis, or congenital conditions. It is not a symptom of macular degeneration, which primarily affects the retina.
B. Astigmatism: Astigmatism is a refractive error due to an irregularly shaped cornea or lens. It is unrelated to macular degeneration, which involves degeneration of the macula—the part of the retina responsible for sharp central vision.
C. Loss of central vision: Macular degeneration leads to progressive deterioration of the macula, resulting in blurred or complete loss of central vision while peripheral vision remains intact. This is a hallmark symptom and significantly affects activities like reading and recognizing faces.
D. Client reports sharp pain: Macular degeneration does not typically cause pain. It is a painless condition, and the presence of sharp eye pain may suggest another acute ocular issue such as glaucoma or injury, not related to macular changes.
Correct Answer is B
Explanation
Rationale:
A. Polyuria: Polyuria is not a typical symptom of alcohol withdrawal. Although chronic alcohol use may affect renal function, withdrawal is more commonly associated with symptoms of autonomic hyperactivity rather than increased urine output.
B. Hypertension: Hypertension is a common manifestation of alcohol withdrawal due to autonomic nervous system overactivity. As the central nervous system adapts to the absence of alcohol, clients may experience elevated blood pressure, tremors, and agitation.
C. Constipation: Constipation is not expected during alcohol withdrawal. Clients are more likely to experience diarrhea or gastrointestinal upset due to nervous system stimulation and stress responses.
D. Bradycardia: Bradycardia is not characteristic of alcohol withdrawal. Instead, clients often present with tachycardia and other signs of heightened sympathetic activity due to the sudden absence of CNS depressant effects.
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