Nokea
The correct sequence to assess the abdomen is
- A. Auscultation, olfaction, observation, palpation, and percussion
- B. Observation, auscultation, palpation, percussion, and olfaction
- C. Observation, palpation, percussion, auscultation, and olfaction
- D. Olfaction, auscultation, observation, palpation, and percussion
- E. Olfaction, observation, auscultation, percussion, and palpation
Correct Answer: B
Rationale: Abdominal assessment starts with observation, then auscultation (before palpation/percussion to avoid altering bowel sounds), followed by palpation, percussion, and olfaction.
You may also like to solve these questions
What type of assessment is performed on admission?
- A. A focused assessment
- B. An initial head-to-toe shift assessment
- C. A comprehensive health assessment
- D. A brief admission systems assessment
- E. Disease and injury assessment
Correct Answer: B,C
Rationale: A comprehensive health assessment (C) is typically performed on admission to gather baseline data, often including an initial head-to-toe shift assessment (B) to evaluate all body systems.
You have just completed an initial shift assessment of your 72-year-old female patient who has congestive heart failure. Which of the following assessment findings causes you the most concern?
- A. Fine papular rash under both breasts
- B. Reports her last BM was 2 days ago
- C. AP 78 regular and distant
- D. Has not voided in 12 hours
- E. Complaints of fatigue
Correct Answer: D
Rationale: Not voiding in 12 hours is concerning in a patient with congestive heart failure, as it may indicate worsening renal perfusion or fluid retention.
You know that it is important to foster rapport and communication with all of your patients. Which of the following actions and interventions would be helpful to increase the effectiveness of your communication and increase nurse-patient rapport?
- A. Talk most of the time you are with the patient so that he or she does not get nervous
- B. Smile frequently
- C. Think of a good nickname you can call the patient to put him or her at ease
- D. Sit in a chair beside the bed and give the patient at least 5 to 10 minutes of your time
- E. Smile and be genuine
- F. Always introduce yourself while you are smiling and explain what you are about to do before you perform an intervention or assessment
- G. Be aware of possible cultural restrictions or influences. Verify them when uncertain
Correct Answer: B,D,E,F,G
Rationale: Smiling, spending time, being genuine, explaining actions, being nonjudgmental, and respecting cultural differences foster rapport and effective communication.
What are the acronyms used to indicate the quadrants of the abdomen?
- A. RLQ
- B. LMQ
- C. LUQ
- D. RMQ
- E. RUQ
- F. LLQ
Correct Answer: A,C,E,F
Rationale: The abdomen is divided into four quadrants: RLQ (right lower quadrant), LUQ (left upper quadrant), RUQ (right upper quadrant), and LLQ (left lower quadrant).
Score the patient responses on the Glasgow Coma Scale. Calculate the patient's total score. Would you consider this patient as having a significant neurological impairment?
- A. Eye opening to pain: 2, Withdraws from pain: 4, Incomprehensible sounds: 2, Total: 8, Significant impairment
- B. Eye opening to pain: 2, Withdraws from pain: 5, Incomprehensible sounds: 2, Total: 9, Moderate impairment
- C. Eye opening to pain: 3, Withdraws from pain: 4, Incomprehensible sounds: 3, Total: 10, Moderate impairment
- D. Eye opening to pain: 2, Withdraws from pain: 4, Incomprehensible sounds: 3, Total: 9, Moderate impairment
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain (2), withdraws from pain (4), incomprehensible sounds (2), total = 8, indicating significant neurological impairment (score ?¤8 is severe).