Examkin

Question

Difficulty: MediumTechniques of Physical Assessment

An 82-year-old client is admitted to the medical unit presenting with new-onset severe abdominal cramping and sudden, unexplained confusion. When conducting the physical examination, which action should the primary nurse execute?

  1. Evaluate the non-tender abdominal quadrants first, reserving the assessment of the painful region for the final step.Answer
  2. B
    Initiate the abdominal examination by percussing and deeply palpating the quadrants before listening for bowel sounds.
  3. C
    Assign the unlicensed assistive personnel to perform a gentle baseline palpation while the nurse obtains the health history.
  4. D
    Document the sudden confusion as an expected age-related cognitive change and focus exclusively on the physical abdominal findings.

Answer

The nurse should evaluate the non-tender abdominal quadrants first, reserving the assessment of the painful region for the final step.
The correct action demonstrates the fundamental principle of minimizing patient discomfort to obtain accurate assessment data. By examining the non-tender areas first, the nurse prevents early muscle guarding and anxiety, allowing for a thorough evaluation of the entire abdomen before focusing on the primary source of pain.

Step-by-Step Solution

1
Analyze the client's presentation.
The client is an older adult with acute abdominal pain and sudden onset confusion (delirium).
Identifying the primary symptoms determines the priorities for the physical assessment and necessary interventions.
2
Recall the principles of abdominal assessment regarding localized pain.
The nurse must examine non-painful areas before assessing the specific area of reported pain.
Premature palpation of a tender area causes severe discomfort and involuntary muscle guarding (rigidity), making the remainder of the abdominal examination impossible to conduct accurately.
3
Evaluate the alternative actions for safety and procedural accuracy.
Altering the assessment sequence (palpating before auscultating), delegating baseline assessments to UAP, and dismissing acute confusion as normal aging are all incorrect and potentially harmful actions.
Eliminating incorrect clinical practices ensures the selected action aligns with evidence-based nursing standards.

Key Concept

Principles of Abdominal Assessment and Clinical Judgment
Rate this question

Topics

Techniques of Physical Assessment

More questions from this topic