24. A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps.
(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen.
Listen to the abdominal arteries using the bell of a stethoscope.
Provide adequate lighting to inspect the abdomen.
Percuss all four quadrants of the abdomen to measure sound quality.
Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the
The Correct Answer is C,B,D,E,A
Choice A rationale:
Checking for areas of tenderness helps to identify any inflammation, infection, or injury in the abdominal cavity.
Choice B rationale:
Listening to the abdominal arteries helps to detect any bruits or abnormal sounds that may indicate vascular problems.
Choice C rationale:
Providing adequate lighting allows the nurse to inspect the abdomen for any abnormalities, such as distension, scars, or lesions.
Choice D rationale:
Percussing the abdomen helps to assess the size and density of the organs, as well as to detect any fluid or gas accumulation.
Choice E rationale:
Locating the liver and spleen borders helps to determine if they are enlarged or displaced.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Determining areas of resonance across the abdomen can help evaluate for gas accumulation, but it is not as sensitive as visual inspection.
Choice B rationale:
Listening for bowel sounds can help assess for bowel function, but it is not reliable in detecting complications.
Choice C rationale:
The nurse should first expose the client's abdomen to look for changes in appearance. This is because sudden, severe abdominal pain after bowel resection could indicate a complication such as anastomotic leak, bowel perforation, or internal bleeding. These conditions can cause signs of peritonitis, such as abdominal distension, rigidity, or bruising. By visually inspecting the abdomen, the nurse can quickly assess for these signs and initiate appropriate interventions.
Choice D rationale:
Performing abdominal palpation can help identify areas of tenderness or masses, but it can also cause pain and discomfort to the client and increase the risk of infection.
Correct Answer is B
Explanation
Choice A rationale:
Having the client nod to indicate understanding may not be sufficient, especially when dealing with complex medical information. It's essential to ensure clear communication, which is best achieved with the assistance of an interpreter.
Choice B rationale:
Recommending an interpreter who is the same gender as the client is a culturally sensitive approach. It ensures the client's comfort and enhances effective communication during the consent process.
Choice C rationale:
Addressing all questions to the interpreter may hinder the direct communication between the nurse and the client. It's crucial to involve the client in the discussion to understand their concerns and provide appropriate information.
Choice D rationale:
Using medical terminology when explaining the procedure might lead to misunderstandings, especially if the client is not familiar with the terminology. Clear, simple language is essential for effective communication.
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