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Difficulty: MediumTechniques of Physical Assessment

A nurse is performing a comprehensive physical assessment on an 80-year-old client admitted with abdominal distention and new-onset confusion. Which action by the nurse demonstrates correct assessment principles?

  1. Auscultating the abdomen in all four quadrants prior to performing percussion or palpation.Answer
  2. B
    Beginning the abdominal examination with deep palpation to rapidly identify areas of tenderness.
  3. C
    Delegating the physical assessment of the client's new-onset confusion to the Unlicensed Assistive Personnel (UAP).
  4. D
    Documenting the client's new-onset confusion as an expected physiological change related to the aging process.

Answer

The nurse should auscultate the abdomen in all four quadrants prior to performing percussion or palpation.
The correct sequence for an abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultation is performed directly after inspection because manipulating the abdomen can increase bowel motility and alter the true baseline bowel sounds, which could result in a false clinical picture.

Step-by-Step Solution

1
Evaluate the requirement for the correct physical assessment sequence.
Identify that the standard assessment sequence (Inspection, Palpation, Percussion, Auscultation) must be altered for the abdomen.
Manipulating the abdomen through palpation or percussion before auscultation can stimulate intestinal activity and artificially alter baseline bowel sounds.
2
Analyze the delegation action.
Determine that assessing a new symptom like sudden confusion requires nursing judgment.
The RN is strictly responsible for all primary assessments and cannot delegate tasks requiring clinical evaluation to a UAP.
3
Analyze the interpretation of the client's neurological symptom.
Recognize that acute confusion in an elderly client is a sign of pathology, not normal aging.
Age-related changes include mild cognitive slowing, but an acute change in mental status (delirium) requires immediate investigation for underlying medical causes.

Key Concept

The correct sequence for abdominal assessment and appropriate recognition of acute pathology in the older adult.
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Techniques of Physical Assessment

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