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. 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.
Correct Answer is ["D","E","F"]
Explanation
A. The client will teach back information about safe crutch walking.This is an essential component of client education and ensures that the client understands how to use crutches safely. However, this statement does not include a specific time frame, making it not a timed SMART goal.
B. The client will demonstrate safe crutch walking.Demonstration of skills ensures the client can safely perform crutch walking techniques. However, without a specific deadline, it does not qualify as a timed component.
C. The client will not lean on the crutches to support their body weight.This statement reinforces proper crutch technique to prevent nerve damage (e.g., axillary nerve compression). However, it lacks a specific timeframe, so it is not a timed SMART goal.
D. The client will ambulate 5 feet in one day. This goal is specific, measurable, and time-bound as it defines both the distance (5 feet) and the timeframe (one day), making it a timed SMART goal.
E. The client will walk 10 feet by day 2. This goal provides clear progression, stating that the client should ambulate 10 feet within two days, making it specific, measurable, and time-limited.
F. The client will walk 20 feet by day 3. This builds on the previous goals, ensuring incremental progress in crutch walking and clear expectations within a set timeframe.
G. The client will explain 4 principles of crutch safety.This is a knowledge-based goal that ensures the client understands the fundamentals of crutch safety. However, no specific timeframe is provided, so it is not a timed component.
H. The client will explain how to keep crutches in safe condition.This supports long-term safety and maintenance of crutches but does not specify when the client should demonstrate this knowledge, making it not a timed SMART goal.
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