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Difficulty: EasyTechniques of Physical Assessment

During the admission process for an older adult client, a nurse conducts a baseline physical evaluation. Which actions indicate that the nurse is applying appropriate physical examination principles? Select all that apply.

  1. Utilizing the bell of the stethoscope to identify low-pitched sounds like vascular bruits.Answer
  2. Applying light palpation before transitioning to deep palpation during the examination.Answer
  3. C
    Palpating the abdominal area prior to auscultating for bowel sounds.
  4. D
    Directing the unlicensed assistive personnel to perform the initial baseline physical assessment.
  5. E
    Attributing the client's acute onset of confusion to a normal physiological change of aging.

Answer

The correct actions include using the bell of the stethoscope for low-pitched sounds and performing light palpation before deep palpation.
Correct physical assessment techniques require the nurse to use appropriate equipment, such as the bell of the stethoscope for low-pitched sounds, and to apply gentle, light palpation before deep palpation to prevent client discomfort and muscle guarding.

Step-by-Step Solution

1
Evaluate the correct sequence of assessment techniques.
Standard assessment follows inspection, palpation, percussion, and auscultation. However, the abdomen requires inspection, auscultation, percussion, and palpation to avoid altering bowel sounds.
Applying the correct sequence ensures accurate clinical findings.
2
Analyze the principles of tool use and palpation.
The bell is used for low-pitched sounds, and palpation should always progress from light to deep.
Proper technique ensures accurate data collection and client safety.
3
Consider nursing delegation and developmental expectations.
Initial assessments are strictly the RN's responsibility, and acute confusion is abnormal across all age groups.
Maintaining scope of practice and recognizing pathology are critical for safe care.

Key Concept

Foundational Techniques and Principles of Physical Assessment
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Topics

Techniques of Physical Assessment

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