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Difficulty: EasyTechniques of Physical Assessment

A newly admitted adult client reports mild gastrointestinal discomfort. The registered nurse is planning to examine the client's abdominal region. Which actions are appropriate for the nurse to include in this examination? Select all that apply.

  1. Request that the client empty their bladder before starting the evaluation.Answer
  2. Listen to bowel sounds in all four quadrants before performing percussion or palpation.Answer
  3. C
    Begin the examination by deeply pressing on the specific quadrant where the client reports discomfort.
  4. D
    Assign the initial evaluation of the client's gastrointestinal status to the assistive personnel.

Answer

The correct actions are to request the client to empty their bladder before starting the evaluation, and to listen to bowel sounds in all four quadrants before performing percussion or palpation.
Requesting the client to empty their bladder promotes comfort and allows for a more accurate examination of the pelvic and abdominal area. Auscultating before percussing or palpating is essential during an abdominal assessment because tactile manipulation can artificially stimulate bowel motility, resulting in false auscultation findings.

Step-by-Step Solution

1
Identify the primary goal of the clinical scenario.
Determine the appropriate preparation and sequence for an abdominal assessment.
Abdominal assessments require specific patient preparation and a unique sequence to obtain accurate physical findings.
2
Evaluate patient preparation actions.
Requesting the client to empty their bladder is an appropriate and correct action.
An empty bladder promotes client comfort and prevents the bladder from obstructing the palpation of other pelvic and abdominal structures.
3
Evaluate the examination sequence.
Auscultating before percussing or palpating is an appropriate and correct action.
Palpating or percussing first can artificially stimulate bowel motility and sounds, leading to inaccurate assessment findings.
4
Evaluate pain management during the assessment.
Beginning with deep pressure on painful areas is an incorrect action.
Painful areas should always be assessed last to prevent involuntary muscle guarding, which can obscure further examination.
5
Evaluate delegation and safety principles.
Assigning the initial assessment to assistive personnel is an incorrect action.
Initial assessments require the clinical judgment of a registered nurse and cannot be safely delegated.

Key Concept

Abdominal Assessment Principles
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Topics

Techniques of Physical Assessment

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