A registered nurse is caring for an 82-year-old client who suddenly reports severe cramping abdominal pain and exhibits new-onset abdominal distension. The nurse prepares to perform a focused physical assessment of the client's abdomen. Which of the following actions demonstrates the correct assessment technique?
- Inspecting the abdomen for contour and symmetry, followed immediately by auscultating all four quadrants using the diaphragm of the stethoscopeAnswer
- BInspecting the abdominal surface, then performing deep palpation over the reported area of pain to assess for guarding before auscultating
- CInstructing the unlicensed assistive personnel (UAP) to auscultate the client's bowel sounds while the nurse contacts the healthcare provider
- DDeferring the physical examination and explaining to the client that sudden bloating and cramping are expected age-related gastrointestinal changes
Answer
Inspecting the abdomen for contour and symmetry, followed immediately by auscultating all four quadrants using the diaphragm of the stethoscope.
The correct sequence for abdominal assessment is inspection, followed immediately by auscultation, then percussion, and finally palpation. Auscultating before percussing or palpating is critical because manual manipulation of the abdomen can stimulate intestinal activity, resulting in artificially altered bowel sounds. Furthermore, the diaphragm of the stethoscope is the correct instrument choice for auscultating the high-pitched sounds of the gastrointestinal tract.
Step-by-Step Solution
Key Concept
Abdominal Physical Assessment Sequence and Delegation
Estimated Time:1m 15s