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Difficulty: MediumTechniques of Physical Assessment

A nurse is admitting an 81-year-old client who presents to the emergency department with diffuse abdominal pain, nausea, and recent episodes of sudden confusion. An unlicensed assistive personnel is available to assist with the admission process. Which action by the nurse demonstrates the appropriate approach to this client's physical assessment?

  1. Auscultating all four abdominal quadrants for bowel sounds before proceeding to percussion and palpation.Answer
  2. B
    Palpating the tender areas of the abdomen first to quickly identify the source of the client's pain.
  3. C
    Assigning the unlicensed assistive personnel to perform the initial abdominal auscultation and report any abnormal sounds.
  4. D
    Interpreting the client's recent episodes of sudden confusion as an expected physiological change associated with advanced age.

Answer

The correct action is auscultating all four abdominal quadrants for bowel sounds before proceeding to percussion and palpation.
When performing a physical assessment of the abdomen, the standard sequence of techniques is purposefully altered. The correct order is inspection, auscultation, percussion, and palpation. Auscultating before palpation and percussion is essential because manual manipulation can stimulate peristalsis, thereby artificially altering the character and frequency of bowel sounds.

Step-by-Step Solution

1
Analyze the required sequence for an abdominal physical assessment.
The standard sequence (inspection, palpation, percussion, auscultation) must be altered for the abdomen to inspection, auscultation, percussion, palpation.
This prevents manual manipulation of the abdomen from artificially altering the frequency or character of bowel sounds.
2
Evaluate the delegation appropriateness for physical assessment tasks.
Initial physical assessments, particularly those requiring clinical judgment like auscultation, must be performed by the registered nurse.
Unlicensed assistive personnel do not have the scope of practice or training to perform initial assessments or interpret clinical findings.
3
Assess the clinical significance of sudden confusion in an older adult.
Sudden confusion is recognized as a red flag for acute illness, not a normal part of aging.
Older adults often present atypically to systemic stress, and sudden cognitive changes mandate thorough investigation for underlying physiological causes.

Key Concept

Abdominal Assessment Sequence and Geriatric Considerations
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Topics

Techniques of Physical Assessment

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