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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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Start using a highchair for feedings: Infants typically begin using a highchair around 6 months of age when they can sit unsupported. At 3 months, using a highchair is unsafe as the infant lacks sufficient head and trunk control.
B. Place no more than one small pillow in the crib: Pillows and soft bedding increase the risk of suffocation and sudden infant death syndrome (SIDS). The safest practice is to keep the crib free of pillows, blankets, and other soft items.
C. Make sure the crib mattress is soft: A firm crib mattress is recommended to reduce the risk of suffocation and SIDS. A soft mattress can create indentations that pose hazards for infants.
D. Remove bibs when the infant is going to sleep: Bibs can become choking or strangulation hazards during sleep. Removing them before sleep reduces the risk of airway obstruction and promotes infant safety.
Correct Answer is B
Explanation
Rationale:
A. Occupational therapist: An occupational therapist helps clients regain skills for daily living and can assess driving ability, but they are not typically responsible for arranging transportation or addressing confidence-related psychosocial issues. A referral may follow but is not the first step here.
B. Social worker: A social worker assists clients with coping and resource coordination, including transportation services, community support, and addressing emotional or confidence barriers. This makes them the most appropriate referral when a client is unsure about attending follow-up care.
C. Primary care provider: While the PCP oversees general medical care and referrals, they are not responsible for coordinating transportation. The nurse can directly initiate a more appropriate referral rather than relying on the PCP for this non-medical concern.
D. Physical therapist: A physical therapist focuses on improving physical function, mobility, and strength. They do not handle transportation issues or confidence concerns related to attending appointments, making them less relevant in this context.
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