The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

inspection

percussion

palpation

auscultation

Answer and Explanation

The Correct Answer is A

A. Inspection: Inspection is always the first step in any physical examination, including abdominal assessments. It allows the nurse to visually assess the abdomen for distension, asymmetry, discoloration, or other abnormalities.

B. Percussion: Percussion is performed after inspection and auscultation. It helps assess the density of abdominal contents but should not be the first step.

C. Palpation: Palpation is performed last in an abdominal exam to avoid altering bowel sounds and causing discomfort. It should be done after inspection, auscultation, and percussion.

D. Auscultation: Auscultation is typically the second step after inspection to listen for bowel sounds before palpation and percussion, which might alter them.

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Correct Answer is C

Explanation

A. 20 lbs: This is a plausible estimate. By 12 months, an infant's birth weight typically triples. Therefore, an 8 lb birth weight would approximately translate to 24 lbs at 12 months.

B. 32 lbs: This estimate is too high. If an infant's birth weight triples by 12 months, an 8 lb birth weight would not be expected to reach 32 lbs.

C. 24 lbs: An infant's weight usually triples by their first birthday. Therefore, an infant born weighing 8 lbs would be expected to weigh about 24 lbs at 12 months.

D. 16 lbs: This is an underestimate. An 8 lb infant would double their birth weight by about 4 to 6 months, and by 12 months, they would typically have tripled their birth weight to around 24 lbs.

A. Obtain a bedside commode for the client's use. B. Limit the client's fluid intake in the evening. C. Put the side rails up and tell the client to call the nurse before voiding. D. Leave a nightlight on in the client's room.

Correct Answer is D

Explanation

A. Obtain a bedside commode for the client's use: While helpful, this might not address the client's fear of walking in a dark room, and it requires transferring, which could still pose a fall risk.

B. Limit the client's fluid intake in the evening: This can prevent nocturnal trips to the bathroom but doesn't directly address safety if the client needs to get up at night.

C. Put the side rails up and tell the client to call the nurse before voiding: Side rails can sometimes increase fall risk if the client attempts to climb over them. It's more beneficial to ensure a safe environment.

D. Leave a nightlight on in the client's room: This provides adequate lighting, reducing the risk of tripping or falling in the dark, which directly addresses the client's concern about safety while walking to the bathroom.

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The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

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Correct Answer is C

Explanation

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Correct Answer is D

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