A nurse is working with a nursing student to care for several clients who have musculoskeletal injuries. The nurse should identify which of the following functions of the musculoskeletal system? (Select All that Apply)

Choice A Reason: Superficial palpation

Superficial palpation is typically performed after auscultation to avoid altering bowel sounds. It involves gently pressing on the abdomen to detect tenderness, masses, or other abnormalities. This step helps in identifying areas that may require deeper examination.

Choice B Reason: Auscultation

Auscultation is performed after inspection and before palpation to listen to bowel sounds without interference. Using a stethoscope, the nurse listens for the presence, frequency, and character of bowel sounds. This step is crucial as palpation can stimulate bowel activity, potentially leading to inaccurate findings.

Choice C Reason: Inspection

Inspection is the first step in an abdominal assessment. The nurse visually examines the abdomen for any abnormalities such as distension, scars, or discoloration. This step provides initial information about the child’s abdominal health and helps guide the subsequent steps of the assessment.

Choice D Reason: Deep palpation

Deep palpation is performed last to assess the deeper structures of the abdomen. This step involves applying more pressure to feel for masses, organ size, and tenderness. It is important to perform this step last to avoid causing discomfort or altering the findings of the other assessment steps.

Choice A Reason: The most important thing is that now you are here, and it is going to get taken care of

While this statement is reassuring, it does not provide the client with the specific information they are seeking about adhesions. Clients often feel more at ease when they understand the cause of their condition. Providing clear and accurate information helps reduce anxiety and empowers the client to be more involved in their care.

Choice B Reason: This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine

This statement is the best response because it directly addresses the client’s question about adhesions. Adhesions are bands of scar tissue that can form after abdominal surgery, causing organs or tissues to stick together. These adhesions can constrict the intestines, leading to a blockage. Providing this explanation helps the client understand the cause of their condition and the reason for the surgery.

Choice C Reason: I will be happy to go and get you some reading materials about this procedure to explain it further

Offering reading materials can be helpful, but it does not immediately address the client’s anxiety or their specific question about adhesions. While additional information can be beneficial, the nurse should first provide a clear and direct explanation to help the client understand their condition.

Choice D Reason: It’s okay. It happens all the time and I’ve seen a lot of clients with this issue

This statement may come across as dismissive and does not provide the client with the information they need. While it is important to reassure the client, it is equally important to provide specific information about their condition. Understanding the cause of their symptoms can help reduce anxiety and improve the client’s overall experience.