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 D

Explanation

Not knowing what triggered the allergic reaction is a significant concern and may indicate a need for allergy testing and evaluation by an allergy specialist. Identifying the trigger allergen is crucial for implementing avoidance strategies, preventing future allergic reactions, and managing the client's overall health and well-being.
A. While the administration of epinephrine indicates the severity of the allergic reaction and the need for immediate treatment, it may not be the most important indication for referral to an allergy specialist on its own.
B. A biphasic reaction refers to the recurrence of symptoms after an initial resolution of an allergic reaction. Biphasic reactions can occur within hours or days after the initial reaction and can be severe or even life-threatening. This, however, does not necessitate need for a specialist.
C. While severe hypoglycemia can occur in some cases of anaphylaxis, it may not be the primary indication for referral to an allergy specialist.

A. Determine the client's level of fluency in his primary language. B. Encourage the client to nod to indicate understanding. C. Speak directly to the interpreter when teaching the client. D. Make sure a family member is present to interpret for the staff.

Correct Answer is A

Explanation

This is important because it allows the nurse to assess the client's ability to communicate in their primary language. Knowing the client's level of fluency helps the nurse determine the most effective communication strategies and whether an interpreter is necessary.

B. While nodding can be a form of nonverbal communication indicating understanding, relying solely on this may not accurately gauge the client's comprehension.

C. Even in the presence of n interpreter, the nurse should speak directly to the client.

D. Family members may not be proficient in both languages or may not accurately convey medical information.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who experienced an anaphylactic reaction. Which of the following findings should the nurse identify as the most important indication for a referral to an allergy specialist?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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