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 ["B","C","E"]

Explanation

A. Obtaining the provider's signature within 8 hours is not applicable to telephone orders.
This action is typically relevant to written orders.
B. Question any part of the order that is unclear or inappropriate. This helps ensure that the nurse fully understands the prescription and can catch any potential errors or discrepancies.
C. Transcribe the order into the client's health record. This step is crucial for documentation and to ensure that all members of the healthcare team have access to the prescribed treatment.
D. Implement a recorded order message if the nurse can hear and understand it clearly.
This is important to have a clear and accurate record of the provider's prescription, especially if there is any ambiguity in the verbal communication.
E. Repeating the order back to the provider is an effective method to confirm accuracy. This read-back process helps to verify that the nurse has understood the prescription correctly, reducing the potential for errors.

A. Ask the client's full name and date of birth. B. Ask a family member to verify the client's identity. C. Verify the client's room number. D. Check the client's name on the medication administration record (MAR).

Correct Answer is A

Explanation

A. This is the correct method for identifying the client before administering medication.
Asking for the client's full name and date of birth is a standard and effective way to ensure that the right medication is given to the right person.
B. Depending solely on a family member to verify the client's identity is not considered a reliable method. While involving family members can be helpful in certain situations, the primary responsibility lies with the nurse to directly confirm the client's identity.
C. Verifying the client's room number is not a sufficient method of client identification.
Room numbers can change, and it's possible for clients to be moved, so relying on this alone is not considered safe practice.
D. Checking the client's name on the medication administration record (MAR) is an important step in medication administration, but it is not the initial method of identifying the client. It's used to confirm that the right medication is being administered to the right person after the client's identity has been established through direct interaction and confirmation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Correct Answer is A

Explanation

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

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