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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Fine hand tremors and pill rolling: These symptoms are more indicative of parkinsonism, which is another extrapyramidal side effect of antipsychotic medications but not specifically tardive dyskinesia.
B. Facial grimacing and eye blinking: Facial grimacing and eye blinking are classic signs of tardive dyskinesia. These involuntary movements of the face are often seen in patients who have been on antipsychotic medications for an extended period.
C. Urinary retention and constipation: Urinary retention and constipation are not typically associated with tardive dyskinesia. These symptoms may be related to other medication side effects or unrelated conditions.
D. Involuntary pelvic rocking and hip thrusting movements: These movements are characteristic of tardive dyskinesia. Involuntary pelvic rocking and hip thrusting can occur as part of the abnormal involuntary movements seen in tardive dyskinesia.
E. Tongue thrusting and lip smacking: Tongue thrusting and lip smacking are classic signs of tardive dyskinesia, particularly involving the orofacial region. These movements can be distressing for patients and may interfere with speech and eating.

A. "I can change who I designate as my health care proxy at any time." B. "I have to choose a family member as my health proxy." C. "I become incapacitated, end-of-life choices will be made by my proxy" D. "The health care proxy does not go into effect until 1 am incapable of making decisions,"

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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

A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take? (Select all that apply)

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

A nurse on a medical-surgical unit is reconciling a newly admitted client's medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information?

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?