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 B

Explanation

A. "I can change who I designate as my health care proxy at any time": This statement is correct. Clients have the right to change their designated health care proxy at any time as long as they are competent to do so. It's important for clients to know that they have flexibility in selecting their proxy based on their preferences and trust in the individual's ability to represent their wishes.
B. "I have to choose a family member as my health proxy": This statement requires clarification. While many clients may choose a family member as their health care proxy, it is not a requirement. Clients have the autonomy to choose any individual they trust to make medical decisions on their behalf, whether it's a family member, friend, or even a legal representative. It's crucial to ensure that the chosen proxy understands the client's wishes and is willing and able to advocate for them.
C. "If I become incapacitated, end-of-life choices will be made by my proxy": This statement is accurate. A health care proxy is designated to make medical decisions on behalf of the client if they become incapacitated and are unable to make decisions for themselves. The proxy is responsible for advocating for the client's wishes, including end-of-life preferences, if outlined in the advance directive or communicated to the proxy beforehand.
D. "The health care proxy does not go into effect until I am incapable of making decisions": This statement is generally correct. Health care proxies typically become active only when the client is deemed incapacitated and unable to make decisions for themselves, as determined by a healthcare provider. However, the specifics may vary depending on state laws and the language of the advance directive document. It's essential for clients to understand when the proxy's authority begins and how it transitions based on their capacity to make decisions.

A. Intermittent abdominal pain following passage of bloody mucus B. Increasing abdominal pain with a non-relaxed uterus C. Painless red vaginal bleeding D. Abdominal pain with scant red vaginal bleeding

Correct Answer is C

Explanation

A. Intermittent abdominal pain following passage of bloody mucus: This description is more consistent with the symptoms of placental abruption, where there is painful bleeding with the passage of blood and mucus. Placenta previa typically presents with painless bleeding.
B. Increasing abdominal pain with a non-relaxed uterus: Increasing abdominal pain with a non-relaxed uterus suggests uterine irritability, which may be indicative of preterm labor rather than placenta previa. Placenta previa typically presents with painless bleeding.
C. Painless red vaginal bleeding: This finding is characteristic of placenta previa. Pain is typically absent or minimal with placenta previa, and the bleeding is bright red due to the richly oxygenated maternal blood flowing from the placental vessels.
D. Abdominal pain with scant red vaginal bleeding: While abdominal pain may occur in some cases of placenta previa, it is typically not the predominant symptom. Additionally, the bleeding associated with placenta previa is typically painless and can be more profuse than scant bleeding.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has named a person to serve as his health care proxy. The client talks about this type of advance directives. Which of the following statements by the client indicates a need for clarification?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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