A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Deep palpation
Light palpation
Auscultation
Inspection
The Correct Answer is D,C,B,A
Rationale:
D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.
C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.
B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.
A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Go to bed at least 2 hours earlier than usual.": Going to bed earlier may increase total sleep time, but it does not directly address the cause of nighttime awakening—frequent urination. Earlier bedtime alone is unlikely to improve the client’s quality of sleep.
B. "Have a snack before bedtime.": A bedtime snack may help prevent nausea or maintain blood sugar levels but does not reduce nighttime urinary frequency. In some cases, it might lead to increased fluid intake, potentially worsening nocturia.
C. "Drink a cup of chamomile tea at bedtime.": While chamomile may promote relaxation, it is also a fluid, which can increase bladder activity during the night. Encouraging tea before bed may worsen the client's urinary frequency and sleep disruption.
D. "Take regular rest periods during the day.": Taking rest periods throughout the day can help reduce overall fatigue and minimize sleep disruption caused by nocturia. Resting during the day compensates for nighttime interruptions and supports maternal well-being in early pregnancy.
Correct Answer is A
Explanation
Rationale:
A. Decreased heart rate: Propranolol is a non-selective beta-blocker that reduces heart rate by blocking beta-1 receptors in the heart. Bradycardia is a common and expected adverse effect, and clients should be taught to monitor their pulse regularly and report significant drops.
B. Sudden weight loss: Sudden weight loss is not a typical adverse effect of propranolol. If it occurs, it may indicate an underlying condition or adverse reaction unrelated to the pharmacologic action of beta-blockers and should be evaluated separately.
C. Increased urinary output: Propranolol does not act on the kidneys to promote diuresis. While beta-blockers may be used in combination with diuretics, increased urine output is not a direct effect of this medication and is not expected.
D. White patches on the tongue: White patches on the tongue suggest oral candidiasis, which is more commonly associated with inhaled corticosteroids, not beta-blockers like propranolol. This symptom is unrelated to the medication’s mechanism of action.
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