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Difficulty: HardTechniques of Physical Assessment

An 82-year-old resident in an assisted living facility has exhibited increased restlessness, intermittent grimacing, and meal refusal over the past 24 hours. The resident has a documented history of chronic constipation. When evaluating this resident's abdominal region, which approach by the nurse is most appropriate?

  1. Observing the contour of the abdomen first, then using the diaphragm of the stethoscope to auscultate all four quadrants prior to initiating percussion and palpation.Answer
  2. B
    Visually checking the abdomen, executing light palpation across all quadrants to identify guarding, and then auscultating for the presence of bowel sounds.
  3. C
    Attributing the recent agitation and anorexia to expected age-related dementia progression, thereby postponing the physical examination.
  4. D
    Assigning the unlicensed assistive personnel to rapidly press on the resident's abdomen to check for distention while preparing the morning medications.

Answer

The nurse must first inspect the abdomen and then auscultate all four quadrants before proceeding to percussion and palpation.
The correct assessment sequence for the abdomen is inspection, followed by auscultation, percussion, and finally palpation. Auscultating prior to percussion and palpation is a critical deviation from the standard physical assessment sequence. It is necessary because manual manipulation of the abdomen can artificially stimulate bowel motility, leading to inaccurate assessment of bowel sounds.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has sudden-onset restlessness, grimacing, and anorexia with a history of constipation, indicating a high probability of an acute abdominal issue.
Identifying the primary clinical problem determines the priority assessment focus.
2
Determine the appropriate physical assessment sequence for the affected body system.
The abdomen requires a specific sequence: inspection, auscultation, percussion, and finally palpation.
Using the standard assessment sequence (inspect, palpate, percuss, auscultate) on the abdomen can artificially stimulate bowel motility, altering normal sounds.
3
Evaluate the options based on nursing principles and safety.
Delegating an assessment to unlicensed personnel is unsafe. Assuming acute symptoms are normal aging is negligent. Palpating before auscultating is an incorrect technique.
Systematically eliminating incorrect nursing actions ensures the selection of the safest, evidence-based practice.

Key Concept

Abdominal Assessment Sequence and Geriatric Considerations
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Topics

Techniques of Physical Assessment

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