Examkin

Question

Difficulty: MediumTechniques of Physical Assessment

A nurse is preparing to perform an abdominal assessment on an older adult client who reports new-onset abdominal cramping and altered bowel habits. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

  1. Instruct the client to empty their bladder before beginning the examination.Answer
  2. Auscultate all four quadrants of the abdomen before performing percussion or palpation.Answer
  3. C
    Delegate the initial baseline auscultation of bowel sounds to the unlicensed assistive personnel (UAP).
  4. D
    Document the sudden onset of altered bowel habits as an expected physiological change of aging.
  5. E
    Begin palpation in the specific quadrant where the client reports the most severe cramping.
  6. Position the client supine with their knees slightly flexed to promote relaxation of the abdominal musculature.Answer

Answer

The correct actions include asking the client to empty their bladder, auscultating before percussing or palpating, and positioning the client supine with knees flexed.
Proper abdominal assessment requires careful preparation, including having the client empty their bladder and positioning them supine with flexed knees to relax the abdominal wall. The sequence of examination must be inspection, auscultation, percussion, and palpation to ensure that mechanical stimulation does not alter bowel sounds.

Step-by-Step Solution

1
Analyze the procedure for preparing a client for an abdominal assessment.
The client should void to ensure comfort and an accurate examination of the pelvic area. They should also be positioned supine with knees flexed to relax the abdominal muscles.
Proper preparation prevents artifacts in assessment, such as mistaking a distended bladder for a mass or encountering voluntary guarding due to muscle tension.
2
Determine the correct sequence for assessing the abdomen.
The correct sequence is inspection, auscultation, percussion, and palpation. Painful areas must be palpated last.
Percussion or palpation before auscultation can alter the frequency and intensity of bowel sounds. Assessing painful areas first causes muscle guarding, compromising the rest of the exam.
3
Evaluate the clinical reasoning regarding delegation and aging.
Initial assessments cannot be delegated to UAPs, and sudden changes in bowel habits are pathological, not a normal part of aging.
The RN is responsible for the nursing process (including baseline assessments). Acute changes in older adults require thorough investigation to rule out serious conditions.

Key Concept

Abdominal physical assessment techniques and nursing principles
Rate this question

Topics

Techniques of Physical Assessment

More questions from this topic