The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?
inspection
percussion
palpation
auscultation
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cognitive dysfunction: This is a broad term that includes various types of cognitive impairment.
B. Alzheimer's disease: This is a specific type of dementia, but it doesn’t specifically describe the timing of confusion.
C. Sundowning syndrome: This term describes increased confusion and agitation in the late afternoon and evening. It’s commonly seen in individuals with dementia.
D. Night-time confusion: This is a general term and doesn't specifically relate to the characteristic pattern of sundowning.
Correct Answer is A
Explanation
A. Ask the client to read a Snellen chart: Cranial nerve II (Optic nerve) is responsible for vision. Assessing the client's ability to read a Snellen chart tests visual acuity, which is a function of cranial nerve II.
B. Listen to the client's speech: This assesses cranial nerves V (Trigeminal) and VII (Facial), which are involved in speech and facial sensation.
C. Ask the client to clench his teeth: This assesses cranial nerve V (Trigeminal), which controls jaw movement and sensation.
D. Ask the client to identify scented aromas: This assesses cranial nerve I (Olfactory), which is responsible for the sense of smell.
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