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) Elevating the bed to a comfortable position for the nurse is important to prevent strain or injury to the nurse's back. However, this action alone does not ensure the client's safety during the transfer.
- B) While acquiring help can be useful, especially for a heavy client or one with limited mobility, it is not the primary action to ensure safety during the transfer.
- C) Placing the wheelchair at a 90° angle to the bed may make the transfer more difficult because it does not allow for the most direct path to the wheelchair.
- D) Locking the wheels of both the bed and the wheelchair is the correct action to take to ensure stability and prevent movement, providing a safe transfer for the client.

A. Wash the tablet off with alcohol and place it in a clean medication. B. Use the tablet's packaging to pick it up from the counter. C. Discard the tablet and obtain another dose of medication. D. Place the tablet directly into a medication cup.

Correct Answer is C

Explanation

A. Washing the tablet off with alcohol and placing it in a clean medication may not effectively remove all potential contaminants and could alter the medication. It's safer to discard it.
B. Using the tablet's packaging to pick it up may not guarantee that the tablet is still clean or free from contamination.
C. Discarding the tablet and obtaining another dose of medication is the safest and most appropriate action. This ensures that the client receives a clean and uncontaminated dose of medication.
D. Placing the tablet directly into a medication cup without any further cleaning is not recommended, as it could introduce potential contaminants into the client's medication.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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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?

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