The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

inspection

percussion

palpation

auscultation

Answer and Explanation

The Correct Answer is A

A. Inspection: Inspection is always the first step in any physical examination, including abdominal assessments. It allows the nurse to visually assess the abdomen for distension, asymmetry, discoloration, or other abnormalities.

B. Percussion: Percussion is performed after inspection and auscultation. It helps assess the density of abdominal contents but should not be the first step.

C. Palpation: Palpation is performed last in an abdominal exam to avoid altering bowel sounds and causing discomfort. It should be done after inspection, auscultation, and percussion.

D. Auscultation: Auscultation is typically the second step after inspection to listen for bowel sounds before palpation and percussion, which might alter them.

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Correct Answer is C

Explanation

A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.

B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.

C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.

D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.

A. Obesity B. Fad dieting C. Anorexia nervosa D. Eating fast foods

Correct Answer is C

Explanation

A. Obesity: While obesity can be linked to a negative self-concept, it is not as closely associated with a "skeletal appearance" as anorexia nervosa.

B. Fad dieting: Fad dieting may indicate concerns about body image, but it does not typically lead to a skeletal appearance and may not necessarily be tied to a deeply negative self-concept.

C. Anorexia nervosa: Anorexia nervosa is characterized by extreme weight loss and a skeletal appearance. It is often associated with a severely negative self-concept and distorted body image, where individuals see themselves as overweight even when they are underweight.

D. Eating fast foods: While this can lead to poor nutritional habits and weight issues, it does not typically lead to a skeletal appearance and is not directly associated with a negative self-concept.

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The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

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