Nokea
The nurse, assisting with data collection of the abdomen, inspects the client’s abdomen. Which assessment technique should the nurse perform next?
- A. Percussion
- B. Auscultation
- C. Light palpation
- D. Deep palpation
Correct Answer: B
Rationale: The correct answer is auscultation. The assessment techniques used for a physical examination are inspection, palpation, percussion, and auscultation. These techniques are normally performed in this order. However, in the abdominal examination, auscultation is performed after inspection and before palpation and percussion. This order is specific to the abdomen because palpation and percussion can increase peristalsis, leading to a false interpretation of bowel sounds. Therefore, auscultation is performed before palpation and percussion in abdominal assessments to ensure accurate bowel sound assessment. Percussion and palpation are performed after auscultation in abdominal assessments. Choices A, C, and D are incorrect as auscultation is the next assessment technique to perform after inspection in abdominal assessments, followed by palpation and percussion.
You may also like to solve these questions
A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?
- A. Holding her breath and using the Valsalva maneuver
- B. Blowing repeatedly in short puffs
- C. Cleansing breaths
- D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction
Correct Answer: B
Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. This breathing technique allows for controlled exhalation and helps prevent unnecessary pushing. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. Holding her breath and using the Valsalva maneuver (choice A) is not recommended as it can increase intra-abdominal pressure and decrease venous return, potentially compromising fetal oxygenation. Deep inspiration and expiration at the beginning and end of each contraction (choice D) are more suitable for relaxation and oxygenation purposes rather than managing the urge to push.
The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?
- A. ''I should eat five or six small meals a day rather than three full meals.''
- B. ''I need to be sure not to drink liquids with my meals.''
- C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
- D. ''I need to avoid eating fried or greasy foods.''
Correct Answer: B
Rationale: To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.
A nurse reviewing the physical assessment findings in a client's health care record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has?
- A. Scoliosis
- B. Bone deformity
- C. Heberden nodules
- D. Carpal tunnel syndrome
Correct Answer: D
Rationale: The Phalen test is specifically used to assess for carpal tunnel syndrome. In this test, the client is asked to hold their hands back to back while flexing the wrists 90 degrees, which can reproduce the numbness and burning sensation experienced by individuals with carpal tunnel syndrome. Scoliosis is a condition characterized by abnormal lateral curvature of the spine, not related to the Phalen test. Bone deformity is a general term that does not specifically relate to the symptoms described. Heberden nodules are bony swellings that occur in osteoarthritis and are not assessed through the Phalen test.
A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?
- A. Contacting the registered nurse
- B. Documenting the findings
- C. Wrapping an extra blanket around the infant
- D. Placing the infant in an oxygen tent
Correct Answer: B
Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.
A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action does the nurse take to test this nerve?
- A. Asking the client to raise their eyebrows and looking for symmetry
- B. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle
- C. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face
- D. Asking the client to close their eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear
Correct Answer: D
Rationale: To test the cochlear portion of the acoustic nerve (cranial nerve VIII), the nurse should have the client close their eyes and indicate when a ticking watch is heard as the nurse moves the watch closer to the client's ear. This action assesses the client's ability to perceive auditory stimuli, as the cochlear portion of the acoustic nerve is responsible for hearing. Choices A, B, and C are incorrect. Asking the client to raise their eyebrows to check for symmetry is a method to test the facial nerve (cranial nerve VII). Asking the client to clench their teeth and palpating the masseter muscles tests the motor component of the trigeminal nerve. Having the client identify light and sharp touch on both sides of the face is a way to test the sensory component of the trigeminal nerve (cranial nerve V).