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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. 1/2 cup of corn: While corn contains some folate, the amount is relatively low compared to legumes and leafy greens. It is not considered one of the best sources of folic acid for meeting the increased demands of early pregnancy.

B. 1/2 cup of cooked lentils: Lentils are among the richest natural sources of folic acid, providing a significant portion of the recommended daily intake. They are especially beneficial during early pregnancy to help prevent neural tube defects in the developing fetus.

C. 1 fried egg: Eggs provide a small amount of folate but are not a primary source. Although eggs offer other important nutrients during pregnancy, they do not meet the body’s high folic acid needs at 8 weeks gestation.

D. 1 slice of toast: Most bread products in some regions are fortified with folic acid, but the quantity in a single slice is minimal. While it can contribute to daily intake, it is not as concentrated a source as legumes like lentils.

A. A middle adult man B. A teenage boy C. An older adult woman D. A preschool-age girl

Correct Answer is B

Explanation

Rationale:

A. A middle adult man: Although some adults up to age 45 can receive the HPV vaccine based on shared decision-making, routine vaccination is not typically initiated in middle adulthood. The vaccine is most effective when given prior to exposure to HPV, ideally during adolescence.

B. A teenage boy: The HPV vaccine is routinely recommended for all adolescents, including boys, starting at ages 11 to 12, with catch-up vaccination through age 26 if not previously vaccinated. It helps prevent various HPV-related cancers and is most effective when administered before sexual activity begins.

C. An older adult woman: HPV vaccination is not routinely recommended for individuals older than 26. While it may be considered up to age 45 in certain situations, it is less beneficial after potential HPV exposure, and routine administration in this age group is not advised.

D. A preschool-age girl: The HPV vaccine is not recommended for children under 9 years old. Initiating the vaccine too early is not effective or necessary, as the immune system response and timing related to potential HPV exposure are best addressed in early adolescence.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about foods that are high in folic acid with a client who is at 8 weeks of gestation. Which of the following foods should the nurse recommend as the best source of folic acid?

Correct Answer is B

Explanation

A nurse in a family practice office routinely reviews clients' immunization status at their annual physical examination visits. For which of the following clients should the nurse recommend a human papillomavirus immunization?

Correct Answer is B

Explanation

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