During the abdominal assessment, why is percussion performed before palpation?
It prepares the patient psychologically for palpation.
It allows detection of fluid waves before causing discomfort.
It helps identify areas that require deeper palpation.
It confirms bowel sound regularity established during auscultation.
The Correct Answer is C
Choice A reason: While establishing rapport is part of an assessment, the sequence of physical examination is based on physiological principles rather than psychological preparation. Percussion provides clinical data about the density of underlying organs and the presence of air or fluid, which dictates how the nurse should safely proceed with palpation.
Choice B reason: Detecting fluid waves is a specific technique for assessing ascites, but it is not the primary reason for the general sequence of the exam. Percussion is used to map out organ boundaries and detect tympany or dullness, which helps the nurse avoid causing unnecessary pain during subsequent palpation.
Choice C reason: Percussion allows the nurse to identify the location, size, and density of underlying structures such as the liver, spleen, and bladder. By identifying areas of tenderness or abnormal masses through percussion first, the nurse can prioritize which quadrants require more cautious, light, or deep palpation to prevent injury.
Choice D reason: Bowel sound regularity is established strictly through auscultation. Percussion and palpation can actually alter the frequency and intensity of bowel sounds by stimulating peristalsis. Therefore, auscultation must always occur before these manual maneuvers to ensure the most accurate representation of the patient's baseline gastrointestinal activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Indoor tanning beds are not safe as they emit concentrated ultraviolet A and ultraviolet B radiation. This exposure significantly increases the risk of DNA damage in skin cells, leading to melanoma and non-melanoma skin cancers. Patients must be taught that artificial UV sources are as hazardous as natural sunlight.
Choice B reason: Chemical sunscreens require approximately 15 to 20 minutes to be fully absorbed into the stratum corneum to provide effective photoprotection. Applying it immediately before or after exposure leaves the skin vulnerable to radiation. This statement demonstrates the patient understands the correct pharmacological application timing for maximum ultraviolet protection.
Choice C reason: Ultraviolet radiation can damage ocular tissues and the periocular skin even on cloudy or overcast days. Constant use of sunglasses that filter 99% to 100% of UVA and UVB rays is necessary to prevent cataracts and macular degeneration. Limiting use to bright days shows an incomplete understanding.
Choice D reason: Sunscreen must be reapplied at least every 2 hours, regardless of activity, because the active ingredients break down over time when exposed to light. Furthermore, sweating and friction from clothing can remove the protective layer. Restricting reapplication only to post-swimming activities significantly increases the risk of solar erythema.
Correct Answer is C
Explanation
Choice A reason: Leaving a workstation unlocked and unattended is a major violation of HIPAA regulations and patient privacy. This allows unauthorized individuals to view or alter sensitive protected health information (PHI), which compromises patient safety and subjects the healthcare provider and institution to significant legal and financial penalties.
Choice B reason: Shared logins prevent the system from creating an accurate audit trail of who accessed or modified a patient's record. Accountability is a cornerstone of healthcare informatics; every action within the Electronic Health Record (EHR) must be traceable to a specific individual to maintain data integrity and security.
Choice C reason: Logging out immediately after completing documentation ensures that no one else can access the patient's data under the nurse's credentials. This practice is the most effective way to prevent accidental or intentional data breaches in a busy clinical environment where multiple staff members share hardware resources.
Choice D reason: Passwords and multi-factor authentication are essential technical safeguards required by law to protect electronic health data. Avoiding passwords would leave the system completely vulnerable to cyberattacks and unauthorized access, significantly endangering the confidentiality, integrity, and availability of the patient's medical history and clinical data.
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