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 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.

A. I use garlic for my menopausal symptoms. B. I use ginger when I get car sick. C. I take ginkgo biloba for a headache. D. I take echinacea to control my cholesterol.

Correct Answer is B

Explanation

Choice A Reason: I use garlic for my menopausal symptoms.

Garlic is not typically used for menopausal symptoms. Common herbal supplements for menopause include black cohosh, red clover, and evening primrose oil. These herbs are known to help alleviate symptoms such as hot flashes and night sweats. Garlic, on the other hand, is more commonly associated with cardiovascular benefits, such as lowering blood pressure and cholesterol levels.

Choice B Reason: I use ginger when I get car sick.

Ginger is well-known for its effectiveness in treating nausea and motion sickness. Studies have shown that ginger can help reduce symptoms of motion sickness, such as dizziness, vomiting, and cold sweats. It works by stabilizing digestive function and maintaining consistent blood pressure, which helps alleviate nausea. Therefore, using ginger for car sickness is a correct and effective use of the supplement.

Choice C Reason: I take ginkgo biloba for a headache.

Ginkgo biloba is not typically used for headaches. It is more commonly used to improve cognitive function and circulation. While some studies suggest that ginkgo biloba may help reduce the frequency and severity of migraines due to its antioxidant properties, it is not a primary treatment for headaches. Other supplements, such as feverfew and butterbur, are more commonly recommended for headache relief.

Choice D Reason: I take echinacea to control my cholesterol.

Echinacea is primarily used to boost the immune system and help fight infections, such as the common cold. There is no substantial evidence to support the use of echinacea for controlling cholesterol levels For cholesterol management, supplements like omega-3 fatty acids, plant sterols, and soluble fiber are more effective.

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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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