An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Screen client for alcohol or controlled drug abuse.

Evaluate client for side effects of routine medications.

Instruct client to demonstrate activities of daily living.

Focus questions to evaluate long term memory.

Answer and Explanation

The Correct Answer is C

A.   Alcohol or drug abuse screening may be important but does not directly assess functional ability.
B.   Medication side effects can impact functionality, but ADLs are a direct measure of independence.
C.   Assessing a client's ability to perform activities of daily living (ADLs) is crucial for determining their functional status and whether they can live independently or need assistance.
D.   Long-term memory evaluation is less important than assessing the client's ability to perform daily tasks.

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Correct Answer is C

Explanation

A. While it is important to palpate the correct quadrant, this is unlikely the cause if the gallbladder cannot be located. The gallbladder is typically located in the right upper quadrant, and the nurse would have been palpating this area. This option does not address the most likely cause.
B. A normal gallbladder might not always be palpable, especially if the client is obese. However, inability to palpate the gallbladder does not necessarily indicate a problem; this is a common finding in obese individuals where fat tissue can obscure the gallbladder.
C. Obesity can make it more difficult to palpate internal structures such as the gallbladder. Excess adipose tissue in the abdominal area can prevent the nurse from feeling the gallbladder during palpation. This is the most likely explanation for the failure to locate the gallbladder.
D. While deeper palpation might be necessary in obese clients, the inability to palpate the gallbladder is more likely due to the obscuring effects of fat, rather than a technique issue. It's a common finding that obesity hinders the ability to palpate organs like the gallbladder.

A. Battle sign. B. Chvostek's sign. C. Romberg sign. D. Babinski sign.

Correct Answer is C

Explanation

A. Battle sign refers to bruising behind the ears and is a sign of head trauma, not intoxication.
B. Chvostek's sign is related to hypocalcemia, not intoxication.
C. Romberg sign assesses for balance issues when standing with eyes closed and is commonly positive in clients with neurological impairment, including intoxication.
D. Babinski sign is related to neurological disorders and would not be directly associated with intoxication.

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An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is C

Explanation

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

Correct Answer is C

Explanation

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