The student nurse is preparing to assess the client while the more experienced nurse assists. Prior to the physical assessment, the client indicates that he has been experiencing severe left lower quadrant pain

Question

Which of the following statements by the student nurse indicates that the student nurse requires further education prior to performing this part of the assessment? 1. "I'm going to start by percussing and palpating the client's left lower quadrant first.".
2. "I will start the abdominal assessment by inspecting the client's abdomen.".
3. "I'm going to auscultate the abdomen prior to percussing the abdomen.".
4. "I need to ask the client about the characteristics of his pain.".

Answer 1

1
Rationale 1: Beginning the assessment with the nontender areas permits the nurse to establish the borders of the affected area. Examination of the painful area can exacerbate symptoms, increase the pain, and force termination of the assessment process. The nurse should delay this part of the assessment until the last portion of the examination.
Rationale 2: The nurse should begin the assessment of the client's abdomen with inspection of the abdomen.
Rationale 3: The nurse should auscultate the client's abdomen, and then percuss the abdomen.
Rationale 4: The nurse should inquire about the characteristics of the client's pain.