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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Correct Answer is D

Explanation

A. Dehydration is unlikely to cause blood-tinged urine. Dehydration can lead to concentrated urine, but it typically does not cause blood in the urine.
B. Pernicious anemia is a condition related to a deficiency in vitamin B12, which can lead to a decrease in red blood cell production. However, it is not directly associated with blood in the urine.
C. Bladder infection can cause blood in the urine, but it is more commonly associated with symptoms such as urinary frequency, urgency, and burning during urination. If blood is present, it is usually due to inflammation of the bladder lining.
D. Prostate enlargement, also known as benign prostatic hyperplasia (BPH), can cause blood-tinged urine. The prostate gland surrounds the urethra, and enlargement can lead to irritation and bleeding from the urinary tract.

A. After palpating the abdomen B. Prior to percussing the abdomen C. Prior to inspecting the abdomen D. After assessing for kidney tenderness

Correct Answer is B

Explanation

A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Correct Answer is D

Explanation

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Correct Answer is B

Explanation

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A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?