Author Question: A nurse is performing a focused abdominal assessment on a child complaining of stomach pain. Which ... (Read 31 times)

rlane42 · **on:** Jun 28, 2018

A nurse is performing a focused abdominal assessment on a child complaining of stomach pain. Which assessment finding warrants immediate action by the nurse?

A.
Complains of pain of 4 on 1-10 scale
B.
Lack of rebound tenderness
C.
Negative obturator sign
D.
Positive heel-drop jarring test

Question 2

A nurse in a community clinic assesses children for signs of failure to thrive (FTT). Which child's assessment finding is most concerning to this nurse?

A.
Child's parent asking questions about feeding
B.
Mother demonstrating improper burping technique
C.
Weight for age and sex at the 4th percentile
D.
Weight for length at 86 of ideal weight

parker125 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
A positive heel-drop jarring test involves having the patient stand on his or her toes for 15 seconds then drop onto the heels. Pain elicited with this assessment is indicative of appendicitis. The patient may also wince when getting off the examination table. The nurse should notify the provider immediately. Pain is nonspecific and needs treatment, but does not need immediate action. A negative obturator sign is normal, as is the lack of rebound tenderness.

Answer to Question 2

ANS: C
No specific diagnostic tests exist for failure to thrive (FTT); however, there are several assessment criteria that can be used to identify children at risk for FTT. One such criterion is weight for age and sex below the 5th percentile. Asking questions about feeding is appropriate. Demonstrating improper burping technique creates an opportunity for teaching the correct process. Improper burping combined with other risk factors may be a concern. Weight for length less than the 85th percentile of ideal weight is a concern, so this child has a normal weight-for-length finding.