A nurse is caring for a client who is exhibiting violent behavior and requires the application of wrist restraints. Which of the following actions should the nurse take?

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.

Choice A Reason:

Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, or sense of identity. It often occurs in response to trauma or extreme stress, allowing the individual to distance themselves from the reality of the situation. In this case, the client is not showing signs of dissociation, such as feeling detached from reality or experiencing memory gaps. Instead, they are avoiding the reality of their partner’s condition.

Choice B Reason:

Denial is a defense mechanism where a person refuses to accept the reality of a situation to avoid dealing with painful emotions. The client’s statement about planning a trip despite their partner’s terminal condition indicates that they are not acknowledging the severity of the situation. This refusal to accept reality helps them cope with the emotional distress associated with their partner’s impending death.

Choice C Reason:

Regression involves reverting to behaviors from an earlier stage of development when faced with stress. This might include actions like thumb-sucking, bed-wetting, or other childlike behaviors. The client’s statement does not indicate a return to earlier developmental behaviors but rather a refusal to accept the current reality.

Choice D Reason:

Displacement is a defense mechanism where negative emotions are redirected from their original source to a less threatening target. For example, someone might take out their frustration with their boss on a family member. In this scenario, the client is not redirecting their emotions but rather avoiding the reality of their partner’s condition.