The nurse is preparing to assess a client's abdomen. Place the ...

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The nurse is preparing to assess a client's abdomen. Place the sequence for an abdominal assessment is the correct order. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.
 
  Response 1. Percussion.
  Response 2. Palpation.
  Response 3. Auscultation.
  Response 4. Inspection.

Question 2

The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment?
 
  1. Downward pressure of 1-2 cm using the finger pads.
  2. Side to side pressure of -1 cm using the finger pads.
  3. Downward pressure of 2-4 cm using the palmar surface of the fingers
  4. Light pressure using the base of the fingers (metacarpophalangeal joints)

[tranoy]

Answer to Question 1

Correct Answer: 4, 3, 1, 2
The nurse alters the usual order of the four basic techniques of assessment when examining the abdomen. The correct order for abdominal assessment is inspection, auscultation, percussion, and finally palpation. Percussing and palpating before auscultating could alter the natural sounds of the abdomen. Assessment always begins with inspection. In the assessment of the abdomen, inspection is followed by auscultation, then percussion, and finally palpation. Inspection, palpation, percussion, and auscultation is the usual order of assessment except when assessing the abdomen.

Answer to Question 2

Correct Answer: 2
Side-to-side palpation of -1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node). Downward depression of 1-2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen. Deep palpation of 2-4 cm (3/4-1  in.) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward. Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus.

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Excellent

[bbburns21]

Gracias!