An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Ask the client to describe how they are feeling.

Administer a PRN dose of a prescribed analgesic.

Document that the client denies pain in the nurse's notes.

Confront the client about inconsistent behavior and response.

Answer and Explanation

The Correct Answer is A

A.   Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B.   Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C.   While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D.   Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

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Correct Answer is C

Explanation

A. Providing frequent rest periods is important for older adults, especially those who may be experiencing fatigue or have chronic conditions. However, this intervention, while supportive, is not always the most critical or directly related to creating a therapeutic environment in all situations.
B. Allowing additional time for tasks is crucial for older adults who may have slower cognitive or physical processes. This approach helps reduce stress and frustration, contributing to a more supportive and therapeutic environment.
C. Placing assistive devices within reach is essential for ensuring safety and promoting independence. It helps older adults perform tasks more easily and reduces the risk of falls or accidents. This intervention is crucial for creating a therapeutic environment as it directly impacts the client’s ability to manage their own care and environment effectively.
D. Speaking slowly and distinctly is important for effective communication, especially if the older adult has hearing or cognitive impairments. It helps ensure that the client understands instructions and information, which is fundamental for their safety and engagement in their care.

A. Determine which member of the nursing staff brought the cup of coffee to the client. B. Consult with the dietician to learn if the client is allowed to drink coffee. C. Remove the coffee from the tray, advising the client that it is not included in the diet. D. Remind the client that no milk or creamer can be added to the coffee.

Correct Answer is C

Explanation

A. While it’s important to understand how the coffee ended up on the tray, determining which staff member made the mistake does not address the immediate issue of ensuring the client’s diet is appropriate. The priority should be to correct the dietary error and ensure that the client receives only what is appropriate for their diet.
B. Consulting with a dietician could provide clarity on dietary restrictions and allowances. However, if the client is on a clear liquid diet, coffee is typically not included because it may have additives (like milk or creamer) or may not be considered suitable for the clear liquid diet.
C. Coffee, unless specified as permissible, generally does not meet the criteria for a clear liquid diet due to its potential to be mixed with non-clear substances and its stimulant properties. Removing the coffee and informing the client of the dietary restriction ensures that the client adheres to the prescribed diet and avoids potential complications or issues with their treatment.
D. This action is not suitable for a clear liquid diet. Coffee itself is typically not allowed on a clear liquid diet, regardless of whether milk or creamer is added. This choice does not address the fundamental issue of the coffee being inappropriate for the client’s diet.

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An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is C

Explanation

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