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

Answer and Explanation

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

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Gloves B. Face shield C. Gown D. Mask

Correct Answer is A

Explanation

A. Gloves should be removed first. This is because the gloves are the items most likely to be contaminated. To remove gloves, grasp the outside edge near the wrist and peel them off, turning them inside out as you go.
B. The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.
C. Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.
D. Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Correct Answer is A

Explanation

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

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A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

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