The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)
Palpation.
Inspection.
Auscultation.
Percussion.
The Correct Answer is B
Inspection, followed by Auscultation, Percussion, and Palpation. Inspection assesses for abdominal contour, symmetry, any visible masses, scars or other abnormalities. Auscultation assesses bowel sounds, and Percussion assesses for any areas of tenderness, and to determine the presence of fluid, gas or masses. Palpation assesses for any masses, areas of tenderness, organ size or other abnormalities. This is the order that allows the nurse to assess the abdomen systematically and accurately.
A: Palpation comes last because it can stimulate bowel sounds, which can make the nurse miss some of the sounds while auscultating.
C: Auscultation must be done before percussion and palpation to prevent altering bowel sounds.
D: Percussion comes before palpation to avoid altering the underlying structures of the abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Change in bowel habits. Change in bowel habits, such as diarrhea, constipation, or a change in stool consistency, is a common early symptom of colon cancer. The nurse should advise clients over age 50 to report any changes in bowel habits to their primary care provider for early intervention.
Choice B is incorrect because abdominal cramping is a common symptom of irritable bowel syndrome and not necessarily an early symptom of colon cancer.
Choice C is incorrect because daily bowel movements are considered normal for some individuals and are not necessarily indicative of colon cancer.
Choice D is incorrect because excess gas is not an early symptom of colon cancer.
Correct Answer is B
Explanation
A decrease in grasp strength. Carpal tunnel syndrome is a condition that occurs when the median nerve, which runs from the forearm into the hand, becomes compressed at the wrist. Common assessment findings include numbness, tingling, and pain in the hand and fingers, weakness in the hand, and a decrease in grasp strength.
Choice A, pain radiating down the dorsal surface of the forearm, is not the correct answer because it is a common symptom of tennis elbow.
Choice C, inability to flex index and middle fingers, is not the correct answer because it is a symptom of trigger finger.
Choice D, tenderness in the affected wrist, is not the correct answer because it is a common symptom of wrist sprains or strains.
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