A nurse is assessing a client’s abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Observe the contours of the client’s abdomen using a penlight.

Determine the presence of bowel sounds by using the diaphragm of the stethoscope.

Systematically percuss the client’s abdomen.

Use fingertips to lightly depress the right lower quadrant of the client’s abdomen.

Press deeply into the client’s upper abdomen left of midline to detect aortic pulsation.

Answer and Explanation

The Correct Answer is A,B,C,D,E

Choice A reason:

Observing the contours of the client’s abdomen using a penlight is the first step in the abdominal assessment. This step involves inspecting the shape, skin abnormalities, masses, and movement of the abdomen. It is essential to perform this step first to gather initial visual information about the abdomen’s condition before proceeding to other assessment techniques.

Choice B reason:

Determining the presence of bowel sounds by using the diaphragm of the stethoscope is the second step in the abdominal assessment. Auscultation should be performed before percussion and palpation to avoid altering the frequency and intensity of bowel sounds. This step helps assess the presence, frequency, and location of bowel sounds, as well as any vascular sounds.

Choice C reason:

Systematically percussing the client’s abdomen is the third step in the abdominal assessment. Percussion helps assess the presence of tympany or dullness, which can indicate the presence of air, fluid, or solid masses in the abdomen. This step provides valuable information about the underlying structures and any abnormalities.

Choice D reason:

Using fingertips to lightly depress the right lower quadrant of the client’s abdomen is the fourth step in the abdominal assessment. Light palpation helps assess the consistency, tenderness, and presence of any masses or rigidity in the abdomen. This step should be performed after percussion to avoid altering the findings.

Choice E reason:

Pressing deeply into the client’s upper abdomen left of midline to detect aortic pulsation is the fifth and final step in the abdominal assessment. Deep palpation helps assess the presence of any deep-seated masses and the aortic pulsation, which can provide information about the vascular status of the abdomen.

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Correct Answer is A

Explanation

Choice A Reason

Eyelashes that curl slightly outward are a normal finding in an eye assessment. This natural curl helps protect the eyes from debris and sweat, and it also aids in the distribution of tears across the eye surface. Eyelashes that curl outward are typical and expected in a healthy individual.

Choice B Reason

Corneas with an opaque appearance are not a normal finding. The cornea should be clear and transparent, allowing light to pass through to the retina. An opaque cornea can indicate various conditions such as corneal edema, scarring, or infection. Therefore, this finding would be abnormal and warrant further investigation.

Choice C Reason

Eyelids that blink involuntarily 30 to 35 times per minute are not within the normal range. The average blink rate for a healthy adult is approximately 15 to 20 times per minute. A significantly higher blink rate could indicate an underlying condition such as dry eye syndrome, blepharospasm, or other neurological issues.

Choice D Reason

Pupils that are 8 to 9 mm in diameter are abnormally large. The normal pupil size ranges from 2 to 4 mm in bright light and 4 to 8 mm in dim light. Pupils that are consistently larger than this range could indicate a condition such as mydriasis, which can be caused by various factors including medications, trauma, or neurological disorders.

A. Move quickly to a position in front of the client. B. Remain upright as the client falls toward them. C. Allow the client to slide down their outstretched leg. D. Place their arms around the client to prevent the fall.

Correct Answer is C

Explanation

Choice A Reason:

Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties.

Choice B Reason:

Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client.

Choice C Reason:

Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor.

Choice D Reason:

Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.

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A nurse is assessing a client’s abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

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