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
The Correct Answer is C
A. Being hard of hearing may affect the client's ability to hear and respond to questions, but it does not explain the flinching response to abdominal palpation.
B. Confusion could certainly be a factor, especially in an older adult who is found wandering. However, the specific response of flinching to abdominal palpation indicates a potential source of pain.
C. The client's flinching when the nurse palpates his abdomen is an indication of pain.
This response, along with the client's limited verbal communication (responding only by nodding and smiling), suggests that the client may be experiencing pain and is unable to express it fully.
D. While a language barrier may affect communication, it does not directly explain the client's physical response of flinching when the abdomen is palpated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Applying the ice bag for 30 minutes at a time is a recommended duration for cold therapy. This helps prevent potential tissue damage from prolonged exposure to cold temperatures.
B. Placing the bag directly on the skin is not recommended, as it can cause frostbite or skin damage. A barrier, such as a thin towel or cloth, should be placed between the ice bag and the skin.
C. Allowing room for some air inside the bag is important to allow the ice to conform to the shape of the injured area. However, the bag should not be overfilled with air.
D. Reapplying the bag 30 minutes after removing it is a good practice, as it allows time for the tissues to warm up before reapplying the cold therapy.
Correct Answer is D
Explanation
A. Contacting the pharmacy might be a good step in some cases, but if the nurse has identified a dosage that is three times higher than usual, it's crucial to address this directly with the prescribing provider first.
B. Asking another nurse to verify is a reasonable step, but ultimately, it's the responsibility of the nurse who identifies the discrepancy to take action.
C. Informing the charge nurse and administering the dose without questioning the provider's order could potentially put the client at risk if the dosage is indeed too high.
D. Contacting the provider to question the dosage is the most appropriate immediate action. It's crucial to seek clarification from the provider regarding the unusually high dosage to ensure the safety and well-being of the client. This step ensures that the client receives the correct and safe medication dosage.
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