The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?
inspection
percussion
palpation
auscultation
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Emergency: This type of assessment is rapid and focuses on identifying and treating life-threatening conditions immediately, such as profuse bleeding from a stab wound.
B. Time-lapse: This assessment compares current client data to previous data to assess progress, which is not appropriate for an acute, life-threatening situation.
C. Focused: While this is a detailed assessment of a specific problem area, an emergency assessment is needed first for immediate threats to life.
D. Initial: This is a comprehensive assessment typically conducted when a client first enters a healthcare setting, but in an emergency, the focus shifts to immediate life-saving measures.
Correct Answer is C
Explanation
A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.
B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.
C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.
D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.
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