After thorough inspection of the abdomen, the next assessment step is:
a. percussion.
b. palpation.
c. auscultation.
d. rectal examination.
C
Assessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence occurs because palpation and percussion can alter the fre-quency and intensity of bowel sounds. Therefore, auscultation is done first.
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A client, aged 16 years, comes to the crisis clinic. The nurse learns the client is being molested by
her uncle. The client told her mother, who accused her of lying. To proceed with crisis intervention, the nurse must assume that a. the client has a demonstrated previous ability to cope. b. the client will not be open to a therapist's intervention. c. the therapist must help the client resolve past and current issues. d. the therapist must assume a passive, nondirective role as the client problem solves.
Which of the following should be included in the nurse's preadministration assessment of a client about to receive adrenocorticotropic hormone (ACTH)? Select all that apply
A) Lung auscultation B) Mental status assessment C) Height D) Pulse E) Skin integrity assessment
During the physical examination of a patient's eyes, the nurse asks the patient to follow the tracing of a giant H with the eyes. What is the nurse assessing in this patient?
A) Pupil reaction to light B) Extraocular movements C) Convergence D) Corneal light reflex
The nursing intervention that takes priority for the nursing diagnosis High Risk for Injury related to presence of Sengstaken-Blakemore tube is
a. massaging bony prominences frequently. b. offering fluids frequently. c. placing a pair of scissors at the bedside. d. restraining the client's hands.