The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling.
Which of the following factors should the nurse identify as a likely explanation for the client's behavior?
He is hard of hearing.
Confusion
Pain
Language barrier
None
None
The Correct Answer is B
A. He is hard of hearing:
This is unlikely. While hearing impairment could explain some difficulty in communication, it would not explain the flinching upon abdominal palpation or the wandering behavior. Hearing-impaired clients typically respond to nonverbal cues or attempt to communicate their understanding in other ways.
B. Confusion:
This is correct. The client's wandering behavior, lack of verbal response, and smiling/nodding without clear understanding are indicative of confusion, which is common in older adults experiencing delirium, dementia, or other cognitive impairments. The flinching during abdominal palpation suggests a physical issue, but the client's inability to articulate his discomfort further supports confusion as a contributing factor.
C. Pain:
While pain could explain the flinching during palpation, it does not account for the wandering behavior or the lack of meaningful verbal communication. Pain may coexist with confusion but is not the primary explanation for his overall behavior.
D. Language barrier:
A language barrier could explain difficulty in verbal communication, but it does not account for the wandering behavior or the flinching upon palpation. Additionally, the family’s ability to communicate with the healthcare team suggests this is not the most likely factor
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Rubbing hands and arms to dry is not the correct action for hand hygiene. After applying soap, hands should be rinsed thoroughly with water and then dried using a clean towel or air dryer.
B. Adjusting the water temperature to feel hot is not recommended for hand hygiene.
Water that is too hot can be uncomfortable and may even cause skin irritation. The water should be comfortably warm.
C. Applying 4 to 5 mL of liquid soap to the hands is the correct action. This provides an adequate amount of soap to create a good lather for effective handwashing.
D. Holding the hands higher than the elbows is not a necessary step for hand hygiene.
The focus should be on thoroughly cleaning the hands, not on the position of the hands in relation to the elbows.
Correct Answer is B
Explanation
A. Requesting a prescription for an indwelling urinary catheter should be considered a last resort. Catheters come with risks of infection and other complications, so they should only be used when other interventions have failed.
B. Taking the client to the bathroom every 2 hours is a proactive approach to managing urinary incontinence in older adults with dementia. This helps ensure that the client has regular opportunities to empty their bladder, reducing the likelihood of accidents.
C. Reminding the client to tell the nurse when he has to urinate may not be effective in clients with dementia, as they may have difficulty recognizing or communicating their need to urinate.
D. Using adult diapers should also be considered a last resort and should not be the primary intervention. While they can provide a temporary solution, they do not address the underlying issue and can contribute to skin problems if not changed frequently.
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