A nurse is performing a physical assessment for a 13-year-old adolescent. Which of the following actions should the nurse take?
Have the child bend forward at the waist and check for asymmetry of the scapula.
Auscultate the abdomen for at least 1 min if bowel sounds are absent.
Use the FACES scale to assess pain.
Observe abdominal movement to determine the respiratory rate.
The Correct Answer is A
A. "Have the child bend forward at the waist and check for asymmetry of the scapula." This maneuver is known as the Adam's forward bend test and is used to screen for scoliosis, which commonly appears during adolescence.
B. "Auscultate the abdomen for at least 1 min if bowel sounds are absent." If bowel sounds are absent, the nurse should listen for at least 5 minutes in each quadrant before concluding they are truly absent.
C. "Use the FACES scale to assess pain." The FACES scale is typically used for younger children (3-7 years old). Adolescents can usually use a numeric rating scale (0-10) for pain assessment.
D. "Observe abdominal movement to determine the respiratory rate." Abdominal breathing is characteristic of infants and younger children. In adolescents, the nurse should observe chest movement to assess respiratory rate.
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Related Questions
Correct Answer is B
Explanation
A. Swaddle the toddler in a blanket. While swaddling may be comforting, it does not effectively prevent the toddler from reaching the incision site. Elbow restraints are a more appropriate choice for limiting arm movement and protecting the incision site.
B. Place the toddler in bilateral elbow restraints. Bilateral elbow restraints are commonly used after cleft lip and palate repair to prevent the toddler from touching or disrupting the incision site. These restraints help protect the surgical area while allowing the child to maintain some mobility.
C. Place the child in a mummy restraint. A mummy restraint (wrapping the child tightly) may be too restrictive and can cause distress, as it limits the child's ability to move freely. Elbow restraints are typically a better choice to prevent injury to the surgical site while still allowing some movement.
D. Obtain a prescription for lorazepam. Lorazepam is a sedative and would not be the first-line approach to managing the child's need to prevent touching the incision site. Using physical restraints is a safer and more effective option.
Correct Answer is A
Explanation
A. Mild hematuria. One of the hallmark signs of glomerulonephritis is hematuria (presence of blood in the urine). Mild hematuria is common and is often associated with glomerular injury, which allows red blood cells to pass through the glomerular filtration barrier.
B. Hyponatremia. Hyponatremia (low sodium levels) is not typically associated with glomerulonephritis. However, in severe cases of kidney dysfunction, fluid retention can lead to dilutional hyponatremia, but it is not a primary finding in glomerulonephritis.
C. Absent urine protein. Proteinuria (presence of protein in the urine) is a common finding in glomerulonephritis due to damage to the glomerular filtration barrier. It is typically present, though the amount may vary.
D. Decreased blood potassium. Hyperkalemia (increased potassium levels) is more commonly seen in acute kidney injury and glomerulonephritis due to decreased kidney function. Decreased potassium levels are not typical in this condition.
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