A patient reports severe abdominal pain around the umbilicus and right lower quadrant (RLQ) as well as nausea and vomiting for 2 days. Place these nursing assessment steps in the correct order.
Notifying the health care provider
Palpating for rebound tenderness
Inspecting for position
Handwashing
Palpating lightly
Auscultating for bowel sounds
The Correct Answer is D, C, F, E, B, A
D. Handwashing: This is the initial step to ensure infection control and prevent the transmission of nosocomial pathogens. It must precede any physical contact with the patient's integument or environment. Maintaining aseptic technique is fundamental to all nursing physical examination protocols.
C. Inspecting for position: Inspection provides visual data on patient distress or abdominal contour without disturbing the viscera. This non-invasive step allows the nurse to observe for signs of peritonitis, such as lying perfectly still. It must be performed before any manual manipulation of the abdomen.
F. Auscultating for bowel sounds: Auscultation follows inspection to ensure that bowel sounds are not artificially altered by manual manipulation or palpation. This sequence prevents the elicitation of false hyperactive or hypoactive sounds. It provides a baseline for peristaltic activity before the abdomen is touched.
E. Palpating lightly: Light palpation identifies areas of muscular guarding and superficial masses while minimizing patient discomfort. This step precedes deep palpation to prevent premature elicitation of severe pain. It helps localize the area of maximal tenderness mentioned in the clinical presentation.
B. Palpating for rebound tenderness: Deep palpation for rebound tenderness is performed last because it often causes significant pain and distress. This is a specific assessment for peritoneal irritation often seen in clinical cases of appendicitis. It provides the final physical evidence of an acute abdominal process.
A. Notifying the health care provider: Communication of findings to the physician is the final step after a comprehensive assessment is documented. This allows the nurse to provide a complete clinical picture, including vital signs and specific abdominal findings. Timely reporting facilitates urgent surgical or medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Production of red blood cells: Hematopoiesis occurs within the red bone marrow found in the epiphyses of long bones and the cavities of flat bones. This process is responsible for the continuous generation of erythrocytes, leukocytes, and thrombocytes. It is a critical physiological role of the skeletal component of the system.
B. Protection of organs: The skeletal structure provides a rigid framework that encases and shields vulnerable internal viscera from mechanical trauma. Examples include the cranium protecting the brain and the thoracic cage safeguarding the heart and lungs. This structural barrier is essential for the survival of vital organs.
C. Energy production: While muscles utilize adenosine triphosphate (ATP) for contraction, the musculoskeletal system is not a primary site for the biochemical production of energy. Energy synthesis via cellular respiration occurs in the mitochondria of all cells, primarily fueled by glucose and lipids. It is a metabolic process rather than a system function.
D. Movement/mobility: Muscles act as the primary engines of the body by contracting and pulling on bones to create levers across joints. This allows for both gross motor activities like walking and fine motor tasks such as writing. It is the most visible and fundamental function of the musculoskeletal system.
E. Reservoir for minerals: Bone tissue serves as a dynamic storage site for essential minerals, specifically calcium and phosphorus. The skeletal system releases these minerals into the bloodstream as needed to maintain homeostatic levels for nerve conduction and muscle contraction. It acts as a biological bank for mineral electrolytes.
Correct Answer is D
Explanation
A. Phalanges and clavicle: The phalanges are the distal bones of the digits involved in grasping, while the clavicle anchors the upper limb to the axial skeleton. Neither bone participates in the rotational mechanics of the forearm. Their anatomical positions are too distal and proximal, respectively, to influence radioulnar rotation.
B. Metacarpal and carpal: These bones form the structural framework of the hand and the wrist joint proper. While they move as a unit during forearm rotation, they do not provide the pivot mechanism required for pronation or supination. Their primary movements include flexion, extension, and radial or ulnar deviation.
C. Humerus and scapula: These bones constitute the glenohumeral joint, which allows for circumduction and rotation of the entire upper extremity. While the humerus provides the proximal origin for some forearm muscles, it does not rotate during isolated forearm supination. The scapula serves as a stable base for shoulder mobility.
D. Radius and ulna: The proximal and distal radioulnar joints allow the radius to rotate around the relatively stationary ulna. This specialized articulation enables the palm to turn upward (supination) or downward (pronation). Functional integrity of these two bones is essential for common activities of daily living following a fracture.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.