The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)
Palpation.
Inspection.
Auscultation.
Percussion.
The Correct Answer is B
Inspection, followed by Auscultation, Percussion, and Palpation. Inspection assesses for abdominal contour, symmetry, any visible masses, scars or other abnormalities. Auscultation assesses bowel sounds, and Percussion assesses for any areas of tenderness, and to determine the presence of fluid, gas or masses. Palpation assesses for any masses, areas of tenderness, organ size or other abnormalities. This is the order that allows the nurse to assess the abdomen systematically and accurately.
A: Palpation comes last because it can stimulate bowel sounds, which can make the nurse miss some of the sounds while auscultating.
C: Auscultation must be done before percussion and palpation to prevent altering bowel sounds.
D: Percussion comes before palpation to avoid altering the underlying structures of the abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Assess the client for the ability to ambulate independently. The highest priority nursing intervention for a client admitted to a neurologic rehabilitation unit following a cerebrovascular accident is to assess the client's ability to ambulate independently. This assessment will help the nurse determine the level of assistance required and develop an appropriate care plan.
Option A. Providing instruction on blood-thinning medication is not the highest priority as it can be done later when the client's ambulation status is stable.
Option C. Including the client in the planning of care and setting of goals is important but not the highest priority in this situation as it can be done after assessing the client's ambulation status.
Option D. Praise the client when using adaptive equipment, is not the highest priority as the client's ambulation status is more important at this point.
Correct Answer is {"dropdown-group-1":"E"}
Explanation
Brudzinski sign is a clinical sign of meningitis, an inflammation of the membranes that cover the brain and spinal cord. It is characterized by reflexive flexion of the knees and hips following passive neck flexion13. To test for this sign, the examiner places one hand on the chest and the other behind the neck of the patient lying flat on the back, and then lifts the head forward. Brudzinski sign was first described by Polish pediatrician Józef Brudziński over 100 years ago. It may be absent, especially in young children.
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