A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

Inform the client that the provider will examine sensitive areas first.

Make sure the room temperature is cool.

Explain to the client what is about to happen.

Provide music as an environmental distraction.

Answer and Explanation

The Correct Answer is C

Explaining the examination process to the client helps reduce anxiety and uncertainty, especially for older adults who may be unfamiliar with the procedures or have concerns about the examination. Providing clear and concise explanations in a respectful manner allows the client to feel more informed and involved in their care, which can enhance their overall experience and cooperation during the examination.

A, Sensitive areas are preferably examined last

B, Examination should be done in relatively warm environment to ensure comfort for the client

D, Distracting the client can help alley anxiety but is not crucial unless the client requests so.

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

Explanation

This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.

B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.

C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.

D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.

A. Assessment of the lower extremities B. Assessment of the posterior thorax C. Assessment of the abdomen D. Assessment of the genitalia and rectum

Correct Answer is D

Explanation

Given the traumatic nature of sexual assault and the potential for re-traumatization, the assessment of the genitalia and rectum should be conducted last. This allows the nurse to build rapport with the client, establish trust, and address any immediate concerns or needs before proceeding with a potentially distressing examination.

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A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

Correct Answer is D

Explanation

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