An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Ask the client to describe how they are feeling.

Administer a PRN dose of a prescribed analgesic.

Document that the client denies pain in the nurse's notes.

Confront the client about inconsistent behavior and response.

Answer and Explanation

The Correct Answer is A

A.   Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B.   Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C.   While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D.   Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

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Correct Answer is A

Explanation

A. This action is essential for effectively representing the client. Developing self-awareness of personal values ensures that the nurse does not impose their own beliefs on the client’s decisions. Instead, the nurse can advocate for the client's wishes based on the client's values and preferences, not their own.
B. While listening to the ethics committee is important, the nurse’s role as an advocate is to represent the client’s wishes and interests, not to dictate actions based on committee discussions. Informing the
client what actions should be taken may not be appropriate if it does not align with the client’s values or
preferences.
C. While it is important to advocate for the client's wishes, challenging team members should be done respectfully and constructively. The goal is not to create conflict but to ensure that the client’s preferences are considered.
D. Educating the client about nursing literature may be helpful, but it is not the primary responsibility of the nurse when serving as an advocate in an ethics committee meeting. The focus should be on
understanding and representing the client’s values and wishes rather than providing educational
information, unless it directly influences the client’s decision-making process.

A. Establish mental status baseline. B. Insert an indwelling urinary catheter. C. Check the accuracy of medication list. D. Obtain a capillary blood glucose level.

Correct Answer is D

Explanation

A. While establishing a mental status baseline is important for assessing the client's overall neurological condition and any potential changes in consciousness or cognition, it is not the immediate priority in this case.
B. Inserting a urinary catheter might be necessary for monitoring urine output, especially if there are concerns about fluid balance or kidney function. However, it is not the immediate priority in this scenario unless there are signs of urinary retention or output issues.
C. Checking the accuracy of the medication list is important for understanding the client's current treatment regimen and any possible drug interactions or errors. However, this action does not directly address the urgent symptoms of fever, nausea, vomiting, and blurred vision, which could be indicative of a more immediate medical issue.
D. Given the client’s history of insulin-dependent diabetes mellitus and the presenting symptoms, obtaining a capillary blood glucose level is the most critical and immediate intervention. The symptoms of fever, nausea, vomiting, and blurred vision can be associated with hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

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An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

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