The patient complains of abdominal pain. Before palpating the abdomen, which action should the nurse perform?
Don sterile gloves.
Elevate the patient’s head.
Percuss all four quandrants.
Auscultate the bowel sounds.
The Correct Answer is D
Choice A reason: Donning sterile gloves is unnecessary for abdominal assessment, as it requires clean gloves to prevent infection. Sterile gloves are used for invasive procedures, not palpation or auscultation. This action is irrelevant to preparing for palpation and wastes resources, per infection control and assessment protocols.
Choice B reason: Elevating the patient’s head may relax abdominal muscles but is not required before palpation. Auscultation precedes palpation to avoid altering bowel sounds by pressure. Elevating the head does not address the need for accurate bowel sound assessment, making it less critical, per abdominal examination sequence.
Choice C reason: Percussing all four quadrants follows auscultation and inspection, not precedes palpation. Percussion assesses organ size or fluid but may disrupt bowel sounds if done before auscultation. Auscultation is prioritized to capture unaltered sounds, ensuring a systematic abdominal assessment, per clinical examination guidelines.
Choice D reason: Auscultating bowel sounds before palpation is essential, as palpation may alter peristalsis, leading to inaccurate findings. Listening for hypoactive or hyperactive sounds identifies abnormalities like obstruction, guiding further assessment. This sequence preserves diagnostic accuracy, aligning with systematic abdominal examination protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Visual acuity measures the clarity of vision, typically tested using a Snellen chart to assess retinal and optic nerve function. Testing cardinal fields of vision evaluates eye muscle coordination, not visual sharpness. This assessment involves cranial nerves III, IV, and VI, not the retina’s ability to resolve fine details, making it irrelevant here.
Choice B reason: Extraocular movements are assessed by testing the cardinal fields of vision, evaluating the coordinated movement of eyes in six directions. This tests cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye muscles. Misalignment or uncoordinated movement may indicate neurological or muscular issues, making this the correct characteristic being assessed.
Choice C reason: Peripheral vision is tested using confrontation tests, assessing the visual field’s outer edges, mediated by retinal rod cells. Cardinal fields of vision testing focuses on eye muscle coordination, not the extent of the visual field. This assessment does not evaluate peripheral retinal function, making peripheral vision an incorrect choice for this procedure.
Choice D reason: Existence of cataracts is assessed via lens opacity examination, often using an ophthalmoscope. Cardinal fields of vision testing evaluates eye movement coordination, not lens clarity. Cataracts impair light transmission to the retina, but this test targets extraocular muscle function and cranial nerve integrity, making cataract assessment irrelevant to this procedure.
Correct Answer is C
Explanation
Choice A reason: Stating the feeding order (cereal, then eggs) dismisses the client’s autonomy, reducing dignity. Offering choice empowers the client, respecting their preferences. This approach lacks patient-centered care, potentially making the client feel controlled, per dignity and psychosocial care principles.
Choice B reason: Assuming the client dislikes being fed is judgmental and undermines dignity, implying resistance. This statement dismisses the client’s feelings, reducing autonomy and respect. A dignified approach involves choice and collaboration, not confrontation, per patient-centered care and ethical nursing standards.
Choice C reason: Asking what part of the meal the client wants first promotes dignity by offering choice and autonomy. It respects the client’s preferences, fostering a sense of control and respect during a dependent task, aligning with patient-centered care and dignity principles in nursing.
Choice D reason: Expressing a wish for more time suggests inadequacy, potentially diminishing the client’s sense of value. This focuses on the nurse’s limitations, not the client’s dignity. Offering choices enhances respect, whereas this statement risks disempowerment, per psychosocial care and dignity standards.
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