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    Ati rn paediatrics nursing 2023 proctored exam

    A nurse is performing a physical assessment for a 13-year-old adolescent. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Observe abdominal movement to determine the respiratory rate: While observing abdominal movement can help count respirations, in adolescents, chest movement should also be assessed since diaphragmatic breathing is less dominant than in infants. B. Auscultate the abdomen for at least 1 min if bowel sounds are absent: Bowel sounds should be assessed for a full minute before concluding they are absent; this is standard practice, but it is not a unique action specific to adolescent assessment. C. Use the FACES scale to assess pain: The FACES pain scale is designed primarily for younger children (typically ages 3 to 8); adolescents generally respond better to numeric or descriptive pain scales. D. Have the child bend forward at the waist and check for asymmetry of the scapula: This is the recommended screening method for scoliosis, which commonly develops during adolescence; assessing scapular asymmetry during forward bending is appropriate and important for this age group.

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