A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?
Percussion
Auscultation
Palpation
Inspection
The Correct Answer is C
Choice A reason: Percussion precedes palpation to assess abdominal resonance and organ size without altering bowel motility. Performing it last risks inaccurate findings, as palpation may stimulate peristalsis, changing resonance patterns. This sequence ensures reliable detection of abnormalities like organomegaly or fluid accumulation in the abdomen.
Choice B reason: Auscultation is done before palpation to capture natural bowel sounds. Manipulation during palpation can alter peristalsis, affecting auscultatory findings. Early auscultation ensures accurate detection of hypoactive or hyperactive bowel sounds, critical for diagnosing conditions like ileus or obstruction in abdominal assessments.
Choice C reason: Palpation is the final step, following inspection, auscultation, and percussion, to assess for tenderness or masses. This sequence prevents manipulation from altering earlier findings, ensuring accurate identification of abdominal abnormalities like peritonitis or organ enlargement, critical for a comprehensive physical examination.
Choice D reason: Inspection is the first step, providing a visual baseline of abdominal appearance, such as distension or scars. Performing it last misses initial cues guiding subsequent steps. Early inspection ensures no manipulation affects visual assessment, vital for identifying external signs of underlying abdominal pathology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Ritualistic behavior is linked to obsessive-compulsive personality disorder, not narcissistic personality disorder (NPD). NPD involves self-focused grandiosity, not repetitive rituals driven by anxiety. These distinct psychological mechanisms make ritualistic behavior an unlikely finding in clients with NPD during assessment.
Choice B reason: Suspiciousness is characteristic of paranoid personality disorder, not NPD. While NPD clients may distrust due to ego threats, this is secondary to their grandiose self-view. Suspicion is not a core NPD trait, as their focus is on admiration, not pervasive mistrust.
Choice C reason: Preoccupation with aging is not a primary NPD feature. NPD clients focus on idealized self-image, but aging fears are more tied to body dysmorphic disorder or general anxiety. This preoccupation is not a diagnostic criterion for NPD in psychological assessments.
Choice D reason: A grandiose sense of self is a core NPD feature, marked by exaggerated self-importance and entitlement. Driven by fragile self-esteem, this trait leads to behaviors like boasting, as defined in DSM-5 criteria, making it an expected finding during assessment of NPD clients.
Correct Answer is C
Explanation
Choice A reason: Experiencing delusions can contribute to agitation, but it is not the strongest predictor of violence. Delusions may lead to unpredictable behavior, but past actions are more reliable indicators, so this factor is less definitive, making it incorrect.
Choice B reason: A history of being in prison indicates past legal issues but not necessarily violent behavior. Incarceration alone is not a direct predictor of future violence, so this factor is less reliable than actual violent history, making it incorrect.
Choice C reason: A history of violent behavior is the best predictor of future violence, as past actions strongly correlate with recurrence, per evidence-based risk assessments. This reliable indicator guides safety planning, making it the correct factor to emphasize in teaching.
Choice D reason: Substance use disorder increases impulsivity and aggression risk, but it is less predictive than a documented history of violence. Substance use is a contributing factor, not the strongest indicator, so this is incorrect compared to past behavior.
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