A nurse inspects the abdomen for skin color, contour, surface characteristics, and symmetry.
What part of the abdominal assessment does the nurse perform next?

Light palpation for tenderness and muscle tone.

Auscultation of the bowel sounds in all four quadrants.

Percussion for tones in all four quadrants.

Deep palpation for masses or aortic pulsations.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Light palpation is typically performed after auscultation to assess for superficial tenderness, muscle tone, and pulsations. Auscultation precedes palpation to avoid inducing artificial bowel sounds or altering existing ones due to manual pressure.

Choice B rationale

Auscultation of bowel sounds in all four quadrants is the next step in the abdominal assessment after inspection. Listening to bowel sounds provides information about the motility of the gastrointestinal tract and should be done before palpation or percussion, which can alter these sounds.

Choice C rationale

Percussion for tones in all four quadrants is usually performed after auscultation and before palpation. Percussion helps to assess the size and density of abdominal organs and to identify the presence of fluid or air.

Choice D rationale

Deep palpation is performed last in the abdominal assessment sequence to evaluate for deeper masses and aortic pulsations. It follows inspection, auscultation, and light palpation, allowing the nurse to gather preliminary information before applying deeper pressure. .

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Adding thickener to fluids helps to increase their viscosity, making them easier to swallow and reducing the risk of aspiration in clients with dysphagia. Dysphagia often results from impaired muscle control in the mouth and throat, and thicker fluids move more slowly, allowing more time for coordination of the swallowing reflex.

Choice B rationale

Placing food on the right side of the client's mouth addresses the left-sided weakness following a stroke. This allows the client to use the stronger, unaffected side of their mouth and throat for better control during chewing and swallowing, minimizing the risk of food pooling on the weaker side and potential aspiration.

Choice C rationale

Serving food at a very hot temperature can impair the client's ability to sense the food in their mouth and can increase the risk of burns, especially with sensory deficits that can occur after a stroke. Warm or room temperature foods are generally recommended for clients with dysphagia to enhance safety and comfort.

Choice D rationale

Instructing the client to tilt her head forward when swallowing helps to close the airway and open the esophagus, facilitating the passage of food and liquids down the throat and reducing the risk of aspiration into the trachea and lungs. This chin-tuck maneuver is a common compensatory strategy for dysphagia. .

A. Canned pineapple. B. Mashed potatoes. C. Celery. D. Pears with skin.

Correct Answer is D

Explanation

Choice A rationale

Canned pineapple, while containing some fiber, typically has a lower fiber content compared to fresh fruits, especially when the skin is removed. The canning process can also reduce the fiber content. A diet rich in fiber promotes bowel regularity, helps control blood sugar levels, and can contribute to lower cholesterol.

Choice B rationale

Mashed potatoes, particularly if made with peeled potatoes, are relatively low in dietary fiber. Most of the fiber in a potato is found in its skin. Fiber is essential for maintaining healthy bowel function, preventing constipation, and contributing to feelings of fullness, which can aid in weight management.

Choice C rationale

Celery is a source of dietary fiber, primarily in its strings. Fiber adds bulk to the stool, facilitating its passage through the digestive system and preventing constipation. Adequate fiber intake is also associated with a reduced risk of cardiovascular disease and certain types of cancer.

Choice D rationale

Pears with skin are an excellent source of dietary fiber. The skin of fruits and vegetables is often rich in fiber. Dietary fiber plays a vital role in digestive health by promoting regularity, preventing constipation, and supporting the growth of beneficial gut bacteria. It also helps regulate blood sugar and cholesterol levels.

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A nurse inspects the abdomen for skin color, contour, surface characteristics, and symmetry.What part of the abdominal assessment does the nurse perform next?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke.Which of the following actions should the nurse take?

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Explanation

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Correct Answer is D

Explanation

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A nurse inspects the abdomen for skin color, contour, surface characteristics, and symmetry.
What part of the abdominal assessment does the nurse perform next?