When assessing the abdomen, which assessment technique is used last?

percussion

auscultation

palpation

inspection

Answer and Explanation

The Correct Answer is C

A. Percussion: Percussion is typically performed before palpation. It helps to detect differences in density of abdominal contents, fluid presence, and gas patterns.

B. Auscultation: Auscultation is performed before any palpation or percussion to prevent altering bowel sounds. It is typically the second step after inspection.

C. Palpation: Palpation is used last during an abdominal assessment to prevent altering the characteristics of bowel sounds and to ensure that any tenderness or abnormal masses are identified after a thorough initial assessment. Palpation can cause changes in bowel sounds and tenderness.

D. Inspection: Inspection is always the first step in any physical examination. It allows for a visual assessment of the abdomen, looking for distension, asymmetry, and skin changes.

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Correct Answer is C

Explanation

A. 20 lbs: This is a plausible estimate. By 12 months, an infant's birth weight typically triples. Therefore, an 8 lb birth weight would approximately translate to 24 lbs at 12 months.

B. 32 lbs: This estimate is too high. If an infant's birth weight triples by 12 months, an 8 lb birth weight would not be expected to reach 32 lbs.

C. 24 lbs: An infant's weight usually triples by their first birthday. Therefore, an infant born weighing 8 lbs would be expected to weigh about 24 lbs at 12 months.

D. 16 lbs: This is an underestimate. An 8 lb infant would double their birth weight by about 4 to 6 months, and by 12 months, they would typically have tripled their birth weight to around 24 lbs.

A. Obtain a bedside commode for the client's use. B. Limit the client's fluid intake in the evening. C. Put the side rails up and tell the client to call the nurse before voiding. D. Leave a nightlight on in the client's room.

Correct Answer is D

Explanation

A. Obtain a bedside commode for the client's use: While helpful, this might not address the client's fear of walking in a dark room, and it requires transferring, which could still pose a fall risk.

B. Limit the client's fluid intake in the evening: This can prevent nocturnal trips to the bathroom but doesn't directly address safety if the client needs to get up at night.

C. Put the side rails up and tell the client to call the nurse before voiding: Side rails can sometimes increase fall risk if the client attempts to climb over them. It's more beneficial to ensure a safe environment.

D. Leave a nightlight on in the client's room: This provides adequate lighting, reducing the risk of tripping or falling in the dark, which directly addresses the client's concern about safety while walking to the bathroom.

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When assessing the abdomen, which assessment technique is used last?

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Correct Answer is C

Explanation

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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