— 降低風險 · MEDIUM · MCQ —
護理師對病人進行身體評估。腹部評估的標準順序為何？
A nurse is performing a physical assessment on a client. Which technique is the standard order for abdominal assessment?
- AInspection, palpation, percussion, auscultation視診、觸診、叩診、聽診
- BInspection, percussion, palpation, auscultation視診、叩診、觸診、聽診
- CPalpation, percussion, auscultation, inspection觸診、叩診、聽診、視診
- DInspection, auscultation, percussion, palpation✓ 正解視診、聽診、叩診、觸診
— Explanation · 中文詳解 —
腹部身體評估的標準順序為：視診（Inspection）、聽診（Auscultation）、叩診（Percussion）、觸診（Palpation）。由於叩診與觸診會刺激腸道蠕動，若先執行，會導致聽診時腸音（Bowel sounds）變異，無法獲得準確的基線數據。因此，必須在聽診後再進行物理觸碰檢查。
The standard sequence for abdominal physical assessment is inspection, auscultation, percussion, and palpation. Because percussion and palpation can stimulate bowel motility, performing them first would alter bowel sounds and prevent the nurse from obtaining an accurate baseline. Auscultation must therefore be completed before any physical manipulation of the abdomen.