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. Battery involves the unauthorized or harmful touching of another person without their consent. Restraint without proper justification could potentially lead to a charge of battery, but the situation described does not involve actual physical contact.
B. Assault involves the threat of bodily harm to another person, creating fear or apprehension that the harm will be carried out. While the threat of restraint might cause fear, actual restraint is necessary to constitute assault.
C. Invasion of privacy refers to the unauthorized intrusion into an individual's private affairs or the public disclosure of private information. It does not apply to the act of physically restraining a client.
D. False imprisonment occurs when an individual is unlawfully restrained or confined against their will. In this scenario, the provider's directive to restrain the client against her wishes constitutes false imprisonment if the restraint is not justified by the client's medical condition or pose an immediate danger to herself or others.

A. "If you don't do your share of the work, I will have to inform the nurse manager" B. "Several staff members have commented that you don't do your fair share of the work." C. "I need to talk to you about unit expectations regarding delegating and completing tasks." D. "You have been very inconsiderate of others by not completing your share of the work."

Correct Answer is C

Explanation

A. "If you don't do your share of the work, I will have to inform the nurse manager"
This statement uses a threatening tone and may escalate the conflict. It does not promote open communication or collaboration to resolve the issue. Additionally, threatening to inform the nurse manager immediately can create a hostile work environment.
B. "Several staff members have commented that you don't do your fair share of the work."
While it's important to address concerns, singling out the staff nurse in front of others may cause embarrassment and defensiveness. It's better to address the issue privately to avoid further conflict and maintain professionalism.
C. "I need to talk to you about unit expectations regarding delegating and completing tasks."
This statement acknowledges the need for a discussion about unit expectations regarding delegating and completing tasks. By expressing the intention to have a conversation, it opens the door for dialogue and collaboration between the charge nurse and the staff nurse. This approach promotes a supportive and constructive environment for resolving conflicts and addressing concerns.
D. "You have been very inconsiderate of others by not completing your share of the work."
This statement is accusatory and confrontational, which can lead to defensiveness and resistance from the staff nurse. It does not facilitate effective communication or problem-solving. Constructive dialogue is essential for addressing conflicts and finding mutually beneficial solutions.

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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.)

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Correct Answer is D

Explanation

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

Correct Answer is C

Explanation

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