A patient has been admitted from the emergency department (ED) with a primary problem of abdominal pain. Diagnostic tests performed in the ED are pending. The nurse focuses an examination on the abdomen and uses the following techniques. Which technique is correct?

Perform auscultation first.

Have patient place folded arms under the head.

Palpate the patient’s painful area first.

Observe the contour of the abdomen while asking the patient to take a deep breath and hold it.

Answer and Explanation

The Correct Answer is A

When assessing a client with abdominal pain, the nurse must follow a specific order of physical assessment techniques: inspection, auscultation, percussion, and palpation-unlike in other systems where palpation may follow auscultation.

Rationale for correct answer:

1. Perform auscultation first: In abdominal assessment, auscultation is performed before percussion and palpation to prevent disturbing the bowel sounds

Rationale for incorrect answers:

2. Have patient place folded arms under the head: Folding arms behind the head tightens the abdominal wall, making it more difficult to palpate or inspect. The correct position is supine with arms at the sides or across the chest to promote relaxation of the abdominal muscles.

3. Palpate the patient’s painful area first: Palpating the painful site first could lead to guarding, involuntary muscle contraction, or missed findings elsewhere.

4. Observe the contour of the abdomen while asking the patient to take a deep breath and hold it. While observing the abdominal contour is appropriate, asking the patient to take a deep breath and hold it is not part of standard abdominal inspection.

Take home points

Always auscultate the abdomen before palpation or percussion to avoid altering bowel sounds and ensure accurate assessment.
Palpate tender areas last and keep the client’s arms at their sides to promote relaxation and allow for a more effective abdominal examination.

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Correct Answer is B

Explanation

Lung assessment is a key component of a comprehensive physical examination. Nurses and healthcare providers use percussion and auscultation to evaluate lung structure and function.

Rationale for correct answer:

2. Resonance over the left upper lobe: Resonance is the expected normal percussion sound over healthy lung tissue, including the left upper lobe. It indicates the presence of air within the alveoli and suggests that the lung is well-aerated.

Rationale for incorrect answers:

1. Tympany over the right upper lobe: Tympany is a high-pitched, drum-like sound typically heard over air-filled organs like the stomach or in cases of a large pneumothorax. It is not normal over lung tissue, including the right upper lobe.

3. Hyperresonance over the left lower lobe: Hyperresonance is louder and lower-pitched than normal resonance and often suggests excess air, as seen in emphysema or a pneumothorax. It is not a normal finding over any lung area and should prompt further evaluation.

4. Dullness above the left 10th intercostal space: Dullness on percussion indicates increased density, such as fluid (pleural effusion) or consolidation (pneumonia). This is not a normal finding and may signal underlying pathology in the lung or pleural space.

Take-home points

Resonance is the normal percussion sound over healthy, aerated lung fields.
Any deviation-such as dullness, tympany, or hyperresonance-may indicate underlying pathology.

A. Facial hair that becomes finer and softer B. Decreased peripheral, color, and night vision C. Increased sensitivity to odors D. An irregular respiratory rate and rhythm at rest

Correct Answer is B

Explanation

Aging brings about predictable and progressive physiological changes in all body systems. These changes are not necessarily indicative of disease but represent a normal part of the aging process.

Rationale for correct answer:

2. Decreased peripheral, color, and night vision: Older adults commonly experience: Decreased peripheral vision (due to retinal changes), Reduced color discrimination (particularly blues and greens), Poorer night vision (due to reduced pupil size and lens transparency).

Rationale for incorrect answers:

1.Facial hair that becomes finer and softer: In older adults, especially women, facial hair may actually become coarser and more noticeable due to hormonal changes, particularly decreased estrogen and relative androgen excess.

3. Increased sensitivity to odors: Olfactory sensitivity declines with age due to loss of olfactory neurons and decreased mucosal receptors. Older adults often have reduced ability to detect and distinguish smells, which can affect appetite and safety (e.g., detecting gas leaks or spoiled food).

4. An irregular respiratory rate and rhythm at rest: While the respiratory system ages (e.g., decreased lung elasticity and vital capacity), a regular rate and rhythm is still expected at rest.

Take home points

Decreased peripheral, color, and night vision are expected in older adults due to physiological changes in the eye (e.g., presbyopia, retinal thinning, and lens clouding).
Unexpected changes in respiratory rhythm or heightened smell sensitivity are not normal with aging and should prompt further clinical evaluation.

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A patient has been admitted from the emergency department (ED) with a primary problem of abdominal pain. Diagnostic tests performed in the ED are pending. The nurse focuses an examination on the abdomen and uses the following techniques. Which technique is correct?

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Which is a normal finding on auscultation of the lungs?

Correct Answer is B

Explanation

Which of the following is an expected finding during assessment of the older adult?

Correct Answer is B

Explanation

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A patient has been admitted from the emergency department (ED) with a primary problem of abdominal pain. Diagnostic tests performed in the ED are pending. The nurse focuses an examination on the abdomen and uses the following techniques. Which technique is correct?

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