A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Superficial palpation

Auscultation

Inspection

Deep palpation

Answer and Explanation

The Correct Answer is C, B, A, D

Inspection: This is the first step because it allows the nurse to gather information through observation without causing any discomfort to the child. It involves looking at the child's abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.

Auscultation: After inspection, the nurse listens to the bowel sounds using a stethoscope. This helps assess peristalsis (movement of food through the intestines) and identify potential problems like bowel obstruction or decreased motility.

Superficial Palpation: This gentle palpation helps assess muscle tone, tenderness, and masses. It's performed after auscultation to avoid altering bowel sounds. Since children are often apprehensive about abdominal exams, starting with a gentler touch can help them feel more comfortable.

Deep Palpation (if necessary): Deep palpation is reserved for last as it can be more uncomfortable for the child. It's used to assess for organomegaly (enlarged organs) or masses that may not be palpable with superficial palpation. It's only performed if there are indications from the first three steps.

Here's a breakdown of why this order is important:

Minimize Discomfort: Starting with non-invasive methods like inspection and auscultation helps establish trust and reduces anxiety in the child, making the overall assessment more cooperative.

Maintain Baseline Bowel Sounds: Palpation can alter bowel sounds, so it's important to listen to them first to get an accurate baseline.

Gradual Progression: Moving from gentle to deeper palpation allows the child to adjust to the sensation and helps the nurse identify potential areas of tenderness before applying deeper pressure.

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Free Nursing Study Resources

Correct Answer is ["0.2"]

Explanation

To calculate the volume of morphine sulfate to administer, we can use the following formula:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

Plugging in the known values:

Dose = 2 mg
Concentration = 10 mg/mL

Volume (mL) = 2 mg / 10 mg/mL

Volume (mL) = 0.2 mL

Therefore, the nurse should administer 0.2 mL of morphine sulfate per dose.

Rounded to the nearest tenth: 0.2 mL

A. Rotate assignment of daily caregivers. B. Provide an activity schedule that changes from day to day. C. Limit time for the client to perform activities. D. Talk the client through tasks one step at a time.

Correct Answer is D

Explanation

A. Rotate assignment of daily caregivers: Consistency in caregivers is important for individuals with Alzheimer's disease to build trust and rapport. Rotating caregivers frequently may disrupt the client's routine and lead to increased confusion and anxiety.
B. Provide an activity schedule that changes from day to day: Consistency and routine are beneficial for individuals with Alzheimer's disease as they provide structure and predictability. A consistent activity schedule helps the client feel more secure and can reduce agitation and behavioral issues.
C. Limit time for the client to perform activities: While it may be necessary to pace activities based on the client's abilities and fatigue level, arbitrarily limiting time for the client to perform activities can be counterproductive. Instead, individualizing the pace of activities based on the client's preferences and abilities is more beneficial.
D. Talk the client through tasks one step at a time: Individuals with Alzheimer's disease often experience cognitive impairment, including difficulty with memory, attention, and problem-solving. Breaking tasks down into manageable steps and providing clear, simple instructions can help the client understand and complete activities of daily living more effectively. This intervention supports the client's independence and reduces frustration.

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A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.2"]

Explanation

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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