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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Minimizing the use of seasoning can decrease palatability and potentially reduce the client's food intake, negatively impacting their nutritional status. Flavorful foods can stimulate appetite and encourage better nutrient consumption.
Choice B rationale
Limiting finger foods may restrict autonomy and reduce intake for clients who have difficulty using utensils. Finger foods can provide independence and increase caloric intake for some individuals in long-term care.
Choice C rationale
Serving small, frequent meals can improve nutritional intake by preventing early satiety and providing a consistent supply of nutrients throughout the day. This approach is often beneficial for individuals with decreased appetite or difficulty tolerating large meals.
Choice D rationale
Offering three large meals daily might be overwhelming for some clients in long-term care who may have reduced appetites, slower digestion, or other medical conditions that make it difficult to consume large quantities of food at once.
Correct Answer is A
Explanation
Choice A rationale
A speech therapist specializes in diagnosing and treating swallowing disorders, such as dysphagia. They assess the client’s ability to swallow safely and provide interventions to improve swallowing techniques, including exercises and modifications to diet. Referral to a speech therapist is essential for managing dysphagia and preventing complications like aspiration pneumonia.
Choice B rationale
A respiratory therapist primarily deals with breathing problems and airway management, not swallowing difficulties. While respiratory therapists play a role in managing clients with respiratory distress, they do not specialize in dysphagia.
Choice C rationale
A dentist focuses on oral health, which is important for overall health, but they are not the appropriate specialist for managing dysphagia. While they may address oral conditions that could impact swallowing, dysphagia management requires the expertise of a speech therapist.
Choice D rationale
A physical therapist focuses on physical movement and rehabilitation. While physical therapy may assist in mobility and motor coordination, dysphagia management falls within the domain of a speech therapist, not a physical therapist.
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