A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?
Percuss
Auscultate.
Palpate.
Inspect
The Correct Answer is D
A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.
B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.
C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.
D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.
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Related Questions
Correct Answer is B
Explanation
A. Prior to percussing the abdomen:
Before percussing, the nurse should listen to bowel sounds. Percussion, a technique used to assess the density of underlying structures, can create vibrations that might interfere with accurate bowel sound assessment.
B. Prior to inspecting the abdomen:
Inspecting the abdomen involves visually assessing the abdominal area for any signs of distension, lesions, or abnormal movements. Bowel sounds are auscultated prior to inspection to avoid stimulating the bowels, which might affect the accuracy of the assessment.
C. After checking for kidney tenderness:
Checking for kidney tenderness, often done by gently percussing the costovertebral angle (CVA), is a separate assessment and does not interfere with bowel sound auscultation. However, bowel sounds are usually assessed before performing any other abdominal assessments to get the most accurate baseline data.
D. After palpating the abdomen:
Palpation involves gently pressing different areas of the abdomen to assess for tenderness, masses, or organ enlargement. Similar to inspection and percussion, palpation can stimulate bowel sounds, so it's essential to auscultate bowel sounds before palpating the abdomen to avoid any interference.
Correct Answer is A
Explanation
A. Prior to percussing the abdomen
Bowel sounds are typically auscultated before performing any other abdominal assessments. This allows the nurse to get an accurate representation of the client's bowel activity without any interference from other assessment techniques.
B. Prior to inspecting the abdomen
Inspecting the abdomen involves observing for any visible abnormalities, such as distension or lesions. Bowel sounds are auscultated first to get an initial sense of the client's gastrointestinal activity.
C. After checking for kidney tenderness
Kidney tenderness assessment is not directly related to bowel sounds. These assessments are separate and do not impact each other's sequence.
D. After palpating the abdomen
Palpating the abdomen should be done after auscultation. Palpation can stimulate bowel activity, potentially altering the natural bowel sounds. Therefore, it is essential to auscultate the abdomen before palpating it.
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