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Difficulty: MediumTechniques of Physical Assessment

During the admission process of a 72-year-old client, the nurse gathers data through various physical examination methods. Which of the following practices reflect appropriate execution and interpretation of the physical assessment? Select all that apply.

  1. Applying the bell of the stethoscope lightly against the skin to auscultate for carotid bruitsAnswer
  2. Depressing the skin 1 to 2 centimeters (0.4 to 0.8 inches) to evaluate for areas of superficial tendernessAnswer
  3. C
    Palpating the four abdominal quadrants deeply before auscultating for bowel sounds
  4. D
    Directing the unlicensed assistive personnel (UAP) to conduct the initial admission skin assessment
  5. E
    Documenting the client's sudden onset of acute confusion as an expected physiological change of aging

Answer

The correct practices are applying the bell of the stethoscope lightly to auscultate for carotid bruits and depressing the skin 1 to 2 centimeters to evaluate for superficial tenderness.
The correct assessment techniques include using the bell of the stethoscope lightly to auscultate for low-pitched sounds (like bruits) and utilizing light palpation (depressing 1 to 2 centimeters) to accurately assess for superficial tenderness. These methods ensure precise data collection without altering the physical findings or causing unnecessary client discomfort.

Step-by-Step Solution

1
Analyze the action regarding stethoscope use.
Applying the bell lightly for bruits is recognized as correct.
The bell is used for low-pitched sounds and requires light pressure to function effectively.
2
Evaluate the action regarding palpation depth.
Depressing 1 to 2 cm for superficial tenderness is recognized as correct.
This is the established standard for light palpation technique across most body systems.
3
Assess the abdominal examination sequence.
Palpating before auscultation is identified as incorrect.
Abdominal assessment must follow the sequence of inspect, auscultate, percuss, and palpate to avoid altering bowel sounds.
4
Review the delegation of the initial assessment.
Delegating the initial skin assessment to a UAP is identified as incorrect.
The RN cannot delegate any initial assessment or clinical judgment to unlicensed personnel.
5
Consider the interpretation of the client's confusion.
Attributing sudden confusion to normal aging is identified as incorrect.
Acute confusion is a hallmark sign of underlying pathology (such as delirium), not a normal age-related change.

Key Concept

Correct execution of physical examination techniques, including appropriate instrument use, examination sequencing, and clinical interpretation of findings.
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Techniques of Physical Assessment

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