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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- Choice A Rationale: This response may provide factual information, but it does not address the client's immediate emotional concern about the colostomy bag, which can lead to feelings of being dismissed or not heard.
- Choice B Rationale: This is an empathetic response that uses reflective listening. It acknowledges the client's concern directly and invites the client to express more about their feelings and concerns, which can help in providing emotional support and further discussion.
- Choice C Rationale: This response delays addressing the client's concern, which may increase anxiety. It is important to discuss concerns as they arise to provide reassurance and to ensure that the client feels supported and understood.
- Choice D Rationale: This response might help the client to connect with others' experiences, but it does not directly address the client's concern about themselves. It could be seen as deflecting the conversation away from the client's personal worries.
Correct Answer is B
Explanation
Choice A rationale:
Providing brochures about the procedure may be helpful, but the immediate concern is the client's expressed lack of understanding.
Choice B rationale:
Notifying the provider is the first action to address the client's concerns and ensure that the client has a clear understanding of the surgery. The nurse should also document the client's statement and the provider's response in the medical record.
Choice C rationale:
Describing the surgery to the client is important, but the provider should be informed first to address the client's immediate concerns.
Choice D rationale:
Completing an incident report is not applicable in this context, as it involves a communication issue rather than an incident.
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