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Difficulty: HardTechniques of Physical Assessment

A triage nurse is evaluating a 76-year-old client presenting from an assisted living facility with a rigid, distended abdomen and a sudden, acute change in mental status. When implementing the physical assessment for this client, which action by the nurse is correct?

  1. The nurse inspects the abdominal skin characteristics, auscultates all four quadrants using the diaphragm of the stethoscope, and then performs light palpation.Answer
  2. B
    The nurse visually assesses the abdominal contour, percusses the suprapubic area for bladder distention, and subsequently auscultates for bowel activity.
  3. C
    The nurse delegates the initial visual inspection of the client's abdomen to the unlicensed assistive personnel (UAP) while preparing intravenous access.
  4. D
    The nurse attributes the sudden mental status change to expected age-related cognitive decline and proceeds directly to deep abdominal palpation.

Answer

The correct action is to inspect the abdomen first, then auscultate all four quadrants with the diaphragm of the stethoscope, followed by palpation.
The proper sequence for an abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultating immediately after inspection is critical because manual manipulation of the abdominal wall can stimulate peristalsis, artificially altering the frequency and character of bowel sounds. Additionally, the diaphragm of the stethoscope is the correct instrument for detecting the high-pitched sounds characteristic of gastrointestinal activity.

Step-by-Step Solution

1
Determine the correct assessment sequence for the abdominal system.
Identify that the abdomen requires a unique sequence: inspection, auscultation, percussion, and finally palpation.
Manipulating the abdomen via percussion or palpation before listening can stimulate peristalsis, creating artificial bowel sounds.
2
Select the correct instrument for the assessment of bowel sounds.
Identify the diaphragm of the stethoscope as the appropriate tool.
The diaphragm is specifically designed to detect high-pitched sounds, such as the gurgling of normal, hypoactive, or hyperactive bowel sounds.
3
Evaluate the distractors related to delegation and lifespan considerations.
Eliminate options involving the UAP and dismissing the client's cognitive changes.
A registered nurse cannot delegate initial assessments, and sudden confusion in older adults is a sign of acute illness (delirium) rather than expected dementia.

Key Concept

Abdominal Physical Assessment Sequence and Geriatric Considerations
Estimated Time:1m 30s
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Topics

Techniques of Physical Assessment

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