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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Correct Answer is D

Explanation

A. "I’m glad my child will have normal bowel movements now.": This statement indicates a misunderstanding of Hirschsprung disease. Surgery for Hirschsprung disease involves removing the portion of the large intestine affected by the condition, which often results in a temporary or permanent colostomy. While surgery aims to improve bowel function, it may not immediately result in normal bowel movements, especially if complications arise or additional surgeries are needed.
B. "I want to learn how to use my child's feeding tube as soon as possible.": This statement suggests a focus on enteral nutrition rather than the surgical management of Hirschsprung disease. While enteral feeding may be necessary for some children with Hirschsprung disease, the primary focus of initial surgery is to remove the affected portion of the large intestine and create an ostomy if needed, rather than addressing feeding tube use.
C. "I want to learn how to empty my child's urinary catheter bag.": This statement pertains to urinary catheter care rather than the surgical management of Hirschsprung disease. While urinary catheters may be used during surgery and recovery, they are not directly related to the treatment of Hirschsprung disease itself.
D. "I'm glad that my child's ostomy is only temporary": This statement demonstrates an understanding of the surgical management of Hirschsprung disease. Many children with Hirschsprung disease require surgery to remove the affected portion of the large intestine and create an ostomy, which may be temporary or permanent depending on the extent of the disease and the child's response to treatment. Recognizing that the ostomy is temporary indicates an understanding of the potential outcomes of surgery and the possibility of eventual bowel anastomosis.

A. Complete an incident report. B. Consent to postexposure treatment with antiretroviral medications C. Request the risk manager obtain consent for HIV testing from the client. D. Wash the site of injury with soap and water

Correct Answer is D

Explanation

A. Complete an incident report: While completing an incident report is important for documentation purposes, it should not be the first action taken after a needle stick injury. Immediate attention to the wound by washing it with soap and water takes precedence to minimize the risk of infection.
B. Consent to postexposure treatment with antiretroviral medications: Postexposure prophylaxis (PEP) with antiretroviral medications may be indicated after a needle stick injury, particularly if there is a risk of exposure to HIV or other bloodborne pathogens. However, obtaining consent for PEP should follow immediate wound care.
C. Request the risk manager obtain consent for HIV testing from the client: While HIV testing may be necessary for the client involved in the incident, it is not the nurse's responsibility to obtain consent for testing. The priority is to address the nurse's own immediate health and safety by cleaning the wound and seeking appropriate medical evaluation and treatment.
D. Wash the site of injury with soap and water: The first action the nurse should take after experiencing a needle stick injury is to immediately wash the site of the injury with soap and water. This helps reduce the risk of infection by removing any potentially infectious material from the wound.

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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 providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse cake first?

Correct Answer is D

Explanation

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